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2010-2788-Minutes for Meeting July 20,2010 Recorded 8/16/2010DESCHUTES COUNTY OFFICIAL NANCY BLANKENSHIP, COUNTY COMMISSIONERS' JOURNAL IIIlilll IIIIIIIIIIIIIIIIIIII III 2010-2788 CLERKRECORDS CJ 2010-2788 08/16/2010 08:37:38 AM Do not remove this page from original document. Deschutes County Clerk Certificate Page ,'>TES G 2 Deschutes County Board of Commissioners 1300 NW Wall St., Suite 200, Bend, OR 97701-1960 (541) 388-6570 - Fax (541) 385-3202 - www.deschutes.ora MINUTES OF MEETING PROPOSED REGIONAL HEALTH AUTHORITY TUESDAY, JULY 209 2010 DESCHUTES COUNTY FAIRGROUNDS, REDMOND, OR Present from Deschutes County were Commissioners Dennis R. Luke and Tammy Baney; Commissioner Alan Unger was unavailiable. Also present were Dave Kanner, County Administrator; Scott Johnson and Kathe Hirschman, Health Services; and Mark Pilliod, County Counsel. In attendance from Crook County were Judge Mike McCabe and Commissioners Lynn Lundquist and Ken Fahlgren; Dave Gordon, County Counsel; and Scott Willard and Muriel DeLa Vergne-Brown, Health Department. Present from Jefferson County were Commissioner Mike Ahern, John Hatfield and Wayne Fording; Jeff Rasmussen, County Administrator; Alexa Gassner, County Counsel; Jeffrey Davis, Mental Health Advisor; and Tom Macharla, Public Health. Others present were Seth Bernstein ofABHA (Accountable Behavioral Health Alliance); Wendy Miller of St. Charles Health Systems; Josh Bishop and Rowena Rosenblum, Pacific Source Health Plans; Rick Treleaven, Best Care Treatment Services; Mike Bonetto of the Oregon Health Policy Board; media representatives of KTVZ TV and The Bulletin; and citizen Seth Crawford. The meeting opened at 1:32 p.m. and introductions were made. Commissioner Tammy Baney gave an overview of the proposal. She explained that the process has taken several years of work at this point. The objective of the joint meeting is to share information and potentially give direction to staff and others on what it will take to move forward on the proposal, if that is what the various entities wish to happen. Minutes of Tri-County Meeting Regional Health Authority Proposal Tuesday, July 20, 2010 Page 1 of 6 Pages It was pointed out that it is clear to all involved that something different needs to be done regarding health services, and everyone has been cooperative during this process. Scott Johnson stated that Mike Bonetto will give an overview of the issue. There are three primary questions to deliberate, as detailed on the agenda. A formal decision should be reached by mid-September on how to proceed. Mr. Bonetto provided a handout (3 separate packets, a copy of which is attached for reference) on the issue. He explained that federal legislation is a primary part of this. There have been a lot of insurance and Medicaid changes lately and more are to come; therefore, it is important to be proactive. The counties need to determine if they are equipped to handle these changes. Payment delivery will change to a global payment or a bundled payment format, which requires integration and efforts to keep people healthier. The counties need to be proactive and not just react to what is bound to happen. The cost of over $800 billion over ten years has a direct impact on the counties. It is not known at this time if this will fall on the backs of the counties. There is an understanding of a future state and some things will not change, such as increases in the senior population and a growth in Medicaid and Medicare. This can be an economic engine for the region if handled properly. Rewarding integration, coordination and population health are important. The federal government will set parameters, but how things are handled will be up to the local entities, and it is not known who will ultimately bear the cost. The number of beneficiaries in this region will increase dramatically in the coming years. Central Oregon ranks at 19.1 % in uninsured in Oregon, as of 2006. It is probably 20% now. This is the highest percentage in the State. The State has started to take some proactive measures. The Oregon Health Authority has been established, which is meant to stimulate innovation, support positive change, etc. BB 2009, addressing organizational change, affects every part of the health delivery system in the State, and therefore that of local governments. The main goals are enhancing the patient experience, improving the health of Oregonians, and reducing the per capita cost of care. Minutes of Tri-County Meeting Regional Health Authority Proposal Tuesday, July 20, 2010 Page 2 of 6 Pages A lengthy discussion occurred regarding the proposal, why change is occurring and is necessary, and how the various entities might address these changes. Consensus was that combining efforts to make the most of resources is the way to go. The group supports care coordination efforts. They are currently investing in physical health aspects, but need to address mental health services. The focus has been on those services being handled through ABHA. There needs to be a coordination of services to the same client base. Questions were raised regarding how long the process might take. This requires a lot of work be done prior to September 15, 2010, including State administration and coordination. Commissioner Baney asked, if not this, what. A comment was made that they could wait for the State to tell them what to do. It was pointed out that there is a timeline for 2014, and if they wait to be proactive they will then be really behind. The biggest advantage of doing something sooner rather than later is to maintain local control. The counties could also end up being categorized in a different district with different partners that they don't want, when things seem to work well already within the tri-county area. Commissioner Luke asked who opposes this concept and whether there is anything to watch out for. It is big enough and this is enough of a change that someone is bound to oppose it. Mr. Bonetto replied they have been working on this for two years. When funding streams are impacted, red flags go up. The State is going to be handcuffed due to federal legislation, and will have to make some decisions regardless. It is easier for them to partner with an established group like this one. It was pointed out that Central Oregon is unique. There is one health care system and the three mental health programs working together as one economic unit. It is easier here. If you throw in Portland or other big cities with a lot of different health plans, hospitals and other entities, and they start feeling insecure, it is a lot more difficult. The field is changing, but some will not want to give up control of health care dollars. Minutes of Tri-County Meeting Regional Health Authority Proposal Tuesday, July 20, 2010 Page 3 of 6 Pages Mr. Johnson said that opposition could come from any group that does not want a government entity taking on a bigger role in anything. Mr. Bonetto stated that the region supports this, but he is not sure what will happen at the State level. If there is pilot program or demonstration project language, that can help mitigate the impacts. If something ends up in statute, there will be more reaction. Questions were raised as to where the Governor and legislators stand on this, and if there is a lot of concern about health records remaining private. Mr. Bernstein replied that the Governor said this is what is needed. It cannot be generalized enough just if Central Oregon does it. Others stated that there are a lot of alternative resources for grants now left on the table, and this will help leverage those when a decision is made. Ms. DeLa Verge-Brown said that they have discussed this proposal with others around the state. A few physicians are not happy about change, but they are in the minority. Orange County, California is taking somewhat of a parallel path. Most entities are a little nervous about the whole thing, but know that change is needed. Commissioner Baney stated that she is attending governance forum talks that address DHS activities and its budget. Regionalization for counties is a hot topic, and AOC has indicated there could be some push-back. Mental health services being taken back by the State is a big factor. Boards are the authorities for mental health and health. Partnerships are not always possible, but the question is, would they give up oversight and retain liability. Mr. Johnson asked the attendees if they are open to doing a letter of intent, moving the contract to a private entity. This means open meetings and open books, with more transparency. Commissioner Luke asked if it would be better to wait for the State to respond. Mr. Johnson replied that the State will still need to do a lot of the work, but they need to know first if the counties are prepared to go forward. The State people will not talk with the federal groups without some assurances. Commissioner Luke asked if Pacific Source would be like a third-party administrator. Mr. Kanner explained that the funding would go to Pacific Source, then to ABHA, and then to the counties. This would be for mental health and chemical dependency services, not for public health. Minutes of Tri-County Meeting Regional Health Authority Proposal Tuesday, July 20, 2010 Page 4 of 6 Pages Seth Bernstein added that there would be no cut for Pacific Source. ABHA would be providing more services, and there should be savings generated to offset any costs. Ms. Rosenblum said that, for instance, as the programs work now, there are potentially three fees attached for services to each individual, and some of this might be eliminated. Mr. Bernstein stated that what is good for ABHA is good for the counties. It was pointed out that the days of passing on cost increases to employees are over. There needs to be change and a working model that will make a difference. The real money is in the savings, and administration costs are incidental. Mr. Johnson said that the State gets federal funding, which is matched with State dollars. Funding goes to COIHS and ABHA, and some is sent to the counties, who contract with providers. The new model would be the regional health authority passing on the dollars to Pacific Source and ABHA to administer. Mr. Bernstein added that during the transition phase, a critical piece is to relinquish control before the regional health authority is established. Mr. Johnson said that there are several things to be accomplished. There needs to be agreement on the concept of a regional health authority at this time. • Legal documents for the regional health authority would be signed in 2012-13. • The contract needs to be approved by September 15, 2010. • There needs to be a legally binding `reset' button for opt-out - a carve-out model instead of combined. • Administrative efficiencies need to be assured by the time of the agreement. • There needs to be a methodology for reinvesting savings. Commissioner Luke asked what control would be given up. Mr. Johnson said that there would be less autonomy and they would become more interdependent. They would be more accountable to the other groups. Discussion occurred about what might happen if one entity wants to drop out or if one should be asked to leave if it is not working; also if Pacific Source or a hospital were to be bought out, or a new mental health director is hired, or other significant changes. Mr. Bernstein said it should not matter; the agreements are in place even if the players change. It needs to be institutionalized to have stability. Minutes of Tri-County Meeting Regional Health Authority Proposal Tuesday, July 20, 2010 Page 5 of 6 Pages Commissioner Luke said he supports the concept, and suggested that the county administrators and their counsels work out the final details; that this needs to be handled by a smaller group. Commissioner Baney indicated agreement. The Board of Crook County agreed. They do not want to wait for the State to impose changes or make decisions for the counties. It is better to do this at the local level and sooner. It could be a pilot program. The Board of Jefferson County also agreed that it makes more sense to be proactive and maintain some control. Mr. Bernstein said that the original deadline for the letter to go to the State was July 1. It was extended until July 22, so needs to be done as soon as possible. Direction was given for the letter of intent to be prepared for signatures. Being no further discussion, the meeting adjourned at 3: 30 p.m. //W, DATED this l / Day of " jj) 2010 for the Deschutes County Board of Commissi ers. D nnis R. Luke, Chair - d-C d z ~ - ATTEST: Recording Secretary Alan Unger, Vice Chair Tammy Baney, Com issioner Minutes of Tri-County Meeting Tuesday, July 20, 2010 Regional Health Authority Proposal Page 6 of 6 Pages z z 0 LU Q W J CL J o ~ 4- Ilb N a s ~ O U ) t3 I J Q) T v v 7 _o VII a0 's. C O L .C L to =3 4 L 00 C ~ C ' T O O o \ c, 0 m 0 v v a z u t^ W %A 'Q W J CL 4 o o N l w O r. Tr 7 "'1 ~ L 1 ~ v cJ p DO 'L C O L 60 4 L D C C ( Z 6 C 0 m L v v m v a Central Oregon Meeting Regional Health Authority Discussion Tuesday July 20, 2010 Deschutes County Expo Center Proposed Agenda a. `vv elcome and Introductions Commissioner Dennis Luke b. Opening Remarks Transitional Board Members Commissioner Mike Ahern Commissioner Tammy Baney Commissioner Ken Fahlgren c. State and National Perspective d. Central Oregon Overview e. Commissioner Deliberation Question 1: Do you support, in principle, the counties, the State, the Hospital system and others creating a Regional Health Authority? Question 2: If yes, should we request that the State channel the Mental Health Organization contract and the Deschutes County Chemical Dependency contract through Pacific Source Central Oregon Individual Health Solutions? (the change would likely take effect in January) Mike Bonetto Oregon Health Authority Board Scott Johnson Deschutes County Health Services Commissioners 1:30 1:35 1:45 2:00 2:15 Question 3: If yes, what should the Letter of Intent require? (the State is requesting a Letter of Intent by July 22 and if the conditions are met, a final decision by September 15) f. Questions of State? Available: Jane-Ellen Weidanz DHS Addictions & MH Division optional g. Next Steps? Commissioners 3:15 h. Adjourn ti Central Oregon Regional Health Authority Discussion July 20, 2010 Central Oregon Meeting "Regional Health Authority" Discussion Crook County Court Deschutes County Board of Commissioners Jefferson County Board of Commissioners July 20 2010 Deschutes County Expo Center Proposed Agenda Welcome, Introductions Commissioner Luke Opening Remarks Commissioners Ahern, Baney and Fahlgren State and National Perspective Mike Bonetto, Oregon Health Policy Board Central Oregon Overview Scott Johnson, Deschutes County COMMISSIONER DELIBERATION: 1. RHA development? 2. Contracting change? 3. Letters of Intent with conditions 7.22? Next steps? 1 Central Oregon Regional Health Authority Discussion July 20, 2010 Recently Passed Federal Legislation ■ Coverage • Estimated to reduce uninsured to 5-10% • Health insurance market reforms • Medicaid expansion & premium assistance ■ Quality • Outcomes research • Best practice areas • Health • Investments in public health * Cost • Price tag = $800 billion over 10 years Consensus of Future State What is believed to be true for all scenarios 1. Medicare & Medicaid will continue, membership will grow, significant payment reductions to community providers 2. Health care will be a major economic development issue. Employers will continue to drop coverage 3. Cost containment will be required and rewarded under any scenario 4. Fee for service payments are going away, larger emphasis from payors and purchasers placed on value and quality 5. Transparency around quality measures and cost will be available to consumers 6. Integration will allow for better care coordination; outcomes 7. Local government will be part of the solution with a regional vision needed to align multiple stakeholders r 2 I i Central Oregon Regional Health Authority Discussion July 20, 2010 Document Reproduces Poorly (Archived) Future of Medicare 2000 2025 Number of beneficiaries 39.5M 69.7M Beneficiaries as share of pop. 13.8% 20.6% 2004 - Medicare accounted for 8% of all federal income taxes. 2015-19% 2025- 32% 2075 - 90% 2017 Medicare Trust Fund assets are exhdusted 3 Central Oregon Regional Health Authority Discussion July 20, 2010 Document Reproduces Poorly (Archived) Solution: At the state level, changing the organization of care... Oregon Health Authority • Stimulate innovation; • New structures for supporting fundamental change; • Linking informal networks to provide comprehensive, coordinated care; • Accountability and Joint responsibility for. keeping people healthy; • Comprehensive performance measurement focusing on quality and outcomes. 4 Goal: Triple Aim A new vision for a healthy Oregon. Oregon's Health Community O Enhance the patient experience through clinical outcomes, patient safety and satisfaction © Improve the health of Oregonians © Reduce per capita cost Document Reproduces Poorly (Archived) Challenge: Too much focus placed on medical care, while disregarding the larger sphere of contributing health factors. Central Oregon Regional Health Authority Discussion July 20, 2010 Human Biology 30% Environmental 5% Social 15% Focus: Medical Care 10% Lifestyle & Behavior 40% 5 Central Oregon Regional Health 1 Authority Discussion July 20, 2010 Document Reproduces POOr{y (Archived) Solution: At the regional level bridge existing gap between medical care and-health and human services constituents. hegun Hea~znr KOr I AHe HE,? r iMjt 11 r.i ll~ i,-, ;;1 ,-c ri Social Service Co 1G_,.~, Regional vision PAYMENT MODELS Fee for service Episode-based reimbursement Partial/full risk capitation Global budgeting INCENTIVES Conduct Evidence-based medicine Expanded care management Reduce obstacles to behavior change Procedures Clinical PIP Risk-adjusted PFP Address root causes METRICS Net revenue Improved clinical outcomes p¢dvice ipreventable hospttallrations/ED Aggregate in health status & OOL Improvement Reduced readmits Reduced disparities Reduced HC costs GOVERNANCE Informal Joint partnerships between organizations Regional Health Authority relationships e.g. mental health & behavioral health Community-based accountability & referrals 6 Central Oregon Regional Health Authority Discussion July 20, 2010 The Central Oregon dialogue Critical issues: Our fragmented system is not sustainable; there is little integration; we lack a comprehensive regional plan; there is a high use of ERs (15 people $367,022; 245 people 2 counties 10+ visits totaling 3,429 visits at $331 each); short life expectancy for people with m.i. a&d (Deschutes: 10 deaths in 2009); 75% of health costs are due to preventable chronic diseases; health costs damage economic development; Oregon faces $2.7 billion deficit (2011-13). Formed 2010 Transitional Board to explore how best to promote a healthy Central Oregon Developed "Links 4 Health" to promote better integration and care for residents of the region Named State Pilot to integrate primary care & behavioral health care in our region Transitional Board 2010 work group to consider a Health Authority Commissioner Tammy Baney (Chair) Deschutes County Rowena Rosenblum (Co-Chair) Pacific Source / COINS Commissioner Mike Ahern Commissioner Ken Fahlgren Dr. Bruce Goldberg Jim Diegel Ken Provencher newmember Megan Haase supports RHA concept Jefferson County Crook County OR Health Authority St. Charles Health System Pacific Source / COIHS Safety Net Clinics Mike Bonetto (ex-officio) OR Health Policy Board Tina Edlund (ex-officio) OR Health Authority 7 Central Oregon Regional Health Authority Discussion July 20, 2010 The Central Oregon Regional Health Authority draft The purpose of the Central Oregon Regional Health Authority is to support the efficient and effective improvement of health outcomes in a fiscally sustainable manner. The primary strategy of the RHA is to institutionalize the collaboration between counties, the Health Plan, the hospital system and providers. The RHA supports this collaboration through contracting and a requirement to report to the RHA as well as the work of an Administrative Council and citizen advisory boards. The Oregon Health Authority contracts directly with the Regional Health Authority. Question #1 Forming a Regional Health Authority? Examples of possible roles 1. Regional health policy Based on the Triple Aim 2. Population health 220,465 5.8% of Oregon; 20,000+ OHP members 3. 5-year Health Improvement Plan and priorities instead of 22 separate plans 4. Health system design 5. Workforce development 6. Advocacy to improve health and health care 7. Manage public funds as determined by Counties 8. Invest public dollars in the health system; secure grants 9. Evaluate and report on the region's health 8 Central Oregon Regional Health Authority Discussion July 20, 2010 Question #1 An RHA? Pros: Cons??: Greater impact on health of Do we know for sure this is the our citizens & satisfaction State's direction? Greater role in decisions re. $200 m. in public funds Greater ability to improve the system and contain costs Greater efficiency if we change, State changes Shared governance role between counties Never done in Oregon Significant effort creating RHA Will the State really streamline administrative requirements? State budget crisis $2.7 billion Changes County authority role into a regional framework Question #1 Forming a Regional Health Authority? Do you support, in principle, the counties, the State, the hospital system and others creating a Regional Health Authority? • Q&A; discussion between counties • Call for question: Crook County ? Deschutes County ? Jefferson County ? If yes, proposed next step: prepare a concept for the counties and Sept. 9 Transitional Board; concepts; ORS 190, 431, 440, bill for 2011 session? 9 Central Oregon Regional Health Authority Discussion July 20, 2010 Question #2 streamline contracts? Do you support shifting MHO and CDO contracts to Pacific Source COIHS as first step in the change process and formation of a Regional Health Authority? Pros: supports care coordination in behavioral health & primary care; ability to share health information; COIHS investment of physical health $ in integration; first step toward RHA in 2012 or 2013; moves ABHA to a BHO, helping people with co-occurring disorders Cons: precedes RHA by 1-2 years; requires significant work by September 15 including administrative efficiencies offered by the Oregon Health Authority; requires a shift toward greater ABHA presence in CO Question 2 If yes to an RHA, should we request that the State channel MHO and CDO contracts thru Pacific Source COIHS in 2012? • Q&A; discussion between counties • Call for question: Crook County ? Deschutes County ? Jefferson County ? 10 J' Central Oregon Regional Health Authority Discussion July 20, 2010 Question #3 If yes to an RHA & contact change; what should the Letter of Intent require (by Sept. 22)? Critical dates for State to execute change in 2011: July 22 Letter of intent with conditions July Aug Sept Meet conditions September 15 Decision by counties, ABHA Proposed Conditions MUST be accomplished 1. Agreement on an RHA concept that is acceptable to counties 2. Legal document assuring contracts will go under RHA in 2012-13 3. Review and OK of contracts before a final decision on Sept. 15 before Sept 15 4. Legally binding reset button counties can execute to form carve out(s) if unsatisfactory 5. Administrative efficiencies assured by time of agreement 6. Methodology for reinvesting any savings DECISION by COUNTIES 11 Central Oregon Regional Health Authority Discussion July 20, 2010 Wrap up / proposed next steps July 22 Conditional letter of intent ABHA for MHO Conditional letter of intent Deschutes for CDO July 30 D.Jarvis workshop: national developments August RHA concept; all conditions must be met Sept - Transitional Board: RHA, conditions met? Sept 15 If conditions met, letters from ABHA and Deschutes County to State requesting contract change Fall: helping clients in four Mosaic/LaPine clinics; one rural health clinic, one pediatric practice, and five school based health centers. Continue work on RHA. 12 Improving the health and health care of people in Central Oregon A possible chronology of events in the public sector 2014 Continual monitoring and imnrovemMt efforts Health coverage expands nationally and in Central Oregon Health Insurance Exchange(s) available to Oregonians 2013 CO Resio afi 1 Health Authori~y~egius invgsjMent ale Oregon contracts State & Federal funds as requested to RHA (or 2012) The RHA and the region's counties invest est'd $250 million RHA invests resources based on Health Improvement Plan 2012 Central Oregon Regional Health Authority, formed Board members appointed; Authority begins operating Region publishes Central Oregon Health Improvement Plan, policies, priorities 2011 Contracts aligned; framework for our RHA is created Oregon contracts with Pacific Source COIHS for all OHP funding Pacific Source contracts with ABHA for all behavioral health services Transitional Board continues to plan new Regional Health Authority Oregon legislature and Central Oregon leaders confront $2.7 billion deficit Potential new legislation to support Regional Health Authority Deschutes County opens health center for health benefit members 2010 Charting a course to exvand an!d imprLwe health in Central Oregon President Obama signs the Affordable Care Act into law Coverage improves through an increase in the OHP population and Healthy Kids Pacific Source purchases Clear One and COIHS, a new partner emerges Central OR stakeholders create a model for integrated care; first 4 clinic sites; 5 school centers 7.20.10 Decision: CO counties support (in concept) for RHA and contract change ? 7.22.10 Decision: ABHA Board Letter of Intent to not renew MHO contract ? 7.22.10 Decision: Deschutes County Letter of Intent to not renew CDO contract ? 7.30 Dale Jarvis presentation on national developments and opportunities 9.9.10 Transitional Board in Jefferson County; RHA Framework, contract language 9.15.10 Decision: transfer of Medicaid contracts from ABHA to COIHS ? Proposed: OHA and region cut costs by streamlining administrative, reporting requirements 2009 A recognized need an opportunity to change Issues indentified: poor client health; shorter life spans; high use of region's ERs, service fragmentation Opportunity: regional integration (Links 4 Health): behavioral health & primary care Oregon passes FIB 2009, initiating development of the Oregon Health Authority Central Oregon named first regional demonstration pilot to integrate services; $150,000 grant Transitional (Health) Board formed to develop a possible structure and priorities for the future. CentralQregon: Excellent relations between counties. Collaboration on health efforts including ABHA governance and investment decisions, H1N1 pandemic response, emergency preparedness, acute care funding and planning, mobile crisis team and residential development as a regional priority. Improving the health and health care of people in Central Oregon A possible chronology of events in the public sector Acronyms ABHA Accountable Behavioral Health Alliance, an organization governed by five counties, one that assures mental health services for OHP members in Crook, Deschutes and Jefferson counties as well as Lincoln and Benton counties BHO Behavioral Health Organization, an organization assigned responsibility for managing integrated mental health and alcohol / drug OHP funds CDO Chemical Dependency Organization (Deschutes County only), a carve out of OHP outpatient alcohol and drug funds for Deschutes County OHP members COIHS Central Oregon Independent Health Services, part of Pacific Source managing public Medicaid funds for a designated region including Central Oregon HB House bill (Oregon Legislature) MHO Mental Health Organization (carve out of OHP mental health services) OHA Oregon Health Authority RHA Regional Health Authority, a new governance structure for the policy, system design, planning and investment of public resources 5. An MOU will be completed and signed by DHS and Central Oregon stakeholders. It will make clear the intent of the proposed contracting arrangements. It will specify the goals and objectives of the demonstration project, how the parties will work together, and how they will know if they have achieved success. 6. Pacific Source will provide either contract language or a letter that is acceptable to ABHA which describes specifically how and under what circumstances savings generated by this integration project will be shared with ABHA. 7. A letter of intent from PacificSource will be made available to Central Oregon stakeholders which states its commitment to ongoing community involvement and intent to contract with ABHA for mental health and chemical dependency services, as described in the MOU. Such community involvement will include: • County oversight of the new contracting arrangement to assure that OHP dollars identified for a given community are invested in said community • Community and consumer input into decisions made about changes to the service delivery system and reinvestments in community services. We will act in good faith to do our part in achieving the milestones noted above. If, despite all our best efforts we do not complete them by the agreed upon deadline, we will continue to work towards achieving them by the next contracting cycle while working with our Central Oregon partners to implement those changes to our service delivery system that do not require a change in contracting.. Respectfully submitted, Linda Modrell, Benton County Commissioner Ken Fahlgren, Crook County Commissioner Tammy Baney, Deschutes County Commissioner Mike Ahern, Jefferson County Commissioner Don Lindly, Lincoln County Commissioner and Governing Board Chair 310 NW Fifth Street, Suite 206 Corvallis, OR 97330 Phone: (541) 753-8997 FAX: (541) 752-4877 Richard Harris Judy Mohr-Peterson State of Oregon Department of Human Services 500 Summer St. NE E-35 Salem, OR 97301-1079 July 22, 2010 Re: Central Oregon Integration Demonstration Project OHP Contracting Dear Richard and Judy: The purpose of this letter is to communicate to you the ABHA Governing Board's intent to terminate its contract with DHS as of December 31, 2010 for OHP mental health services provided by ABHA in Crook, Deschutes, and Jefferson. The Governing Board expects as of January 1, 2011 to be providing an expanded array of services to OHP members through a contract with COINS. This array will include all the mental health services currently provided through ABHA, plus the chemical dependency services currently covered under DHS contracts with COIHS and the Deschutes County CDO. Our ultimate goal is to deliver integrated healthcare to our shared members that results in better outcomes and cost savings. By September 15, 2011 we hope to be able to submit a letter to you that formalizes this commitment. To do so, all of the following implementation milestones will need to have been achieved: 1. There will be agreement by Pacific Source/COINS, ABHA, the Central Oregon counties, and the Oregon Health Authority that all entities agree to contract for OHP and other publically funded services for the three Central Oregon counties through the new Central Oregon Regional Health Authority once it is formed and functionally able to contract for services; 2. A full DHS contract with COIHS as well as a COIHS contract with ABHA will be made available for attorney and Board review and found to be acceptable; 3. DHS will issue a letter or memorandum of understanding to COIHS and the ABHA Governing Board, agreeable to both organizations, which states the specific conditions and mechanisms by which ABHA, COIHS, and/or DHS can independently "reset" contracting and funding to the current state of MHO contracting if this demonstration project is not achieving its goals or working as expected. If such a provision is executed, DHS will reestablish its MHO contract with ABHA for the provision of mental health services for the OHP members Crook, Deschutes, and Jefferson counties. It is understood, that DHS's contracting with MHOS might look different than it is today at the time a reset option is exercised. 4. DHS, ABHA, and COIHS will have signed off on a document titled DHS Oversight and Reporting Processes, which describes in detail how non-duplicative oversight and reporting process will occur under the proposed contracting arrangement. A, &INN KIV PacificSource HEALTH PLANS July 8, 2010 County Commissioners, As part of PacificSource Health Plan's recent acquisition of Clear One Health Plans and Central Oregon Independent Health Solutions (COINS), PacificSource has been asked to comment on its commitment to the ongoing work undertaken by multiple central Oregon community partners related to integrating management of physical, behavioral, and chemical dependency care. As a community-based not-for-profit health plan, PacificSource feels strongly about its responsibility to support and play an active role in this collaboration. We feel this innovative and integrated model will play a unique role in demonstrating how member-centric care can be provided at a community level consistent with the Triple Aim tenets of delivering the highest possible quality care, achieving cost efficiency, and enhancing member satisfaction. PacificSource endeavors to be an equal participant in this process, and is committed to working with,,other individuals and organizations to develop a mutually-acceptable governance model, maintain the voice and opinion of individual communities, play a role in the development of a Regional Health Authority in central Oregon, and find ways to create a new vision for care delivery in central Oregon that will demonstrate a model worth emulating throughout Oregon. PacificSource has a longstanding history of community collaborations ranging from our work with various Oregon physicians to develop sustainable Medical Home models, our leadership role in access initiatives throughout Oregon, and our commitment to provide resources to providers who have innovative ideas for community health improvements. As such, we see the current efforts of the state of Oregon, Accountable Behavioral Health Alliance, health care leaders within Crook, Deschutes and Jefferson counties, Mosaic Medical and other central Oregon health system leaders, as being a unique fit with PacificSource's mission to make a positive and significant difference in helping people get the health care they need. Please let me know how our organization can answer any questions you may have, or if we can provide further information regarding our common objectives and values. Sincerely, r ~1~'tvJ Kenneth P Provencher President and CEO Band Eugene Medford Portland Boise Coeur d'Alene Idaho Falls PacificSourca.com L4H Health Integration Project Transitional Board June Its, 20iO LEGAL WORK GROUP UPDATE A. Purpose of RHA Medicare/behavior health only? Single point of contracting/accountability for state funds Coordinated contracting with service providers 2. Broader healthcare issues? - Environmental health, nutrition, water supply, physical health 3. Regional multi-year Health Improvement Plan (as substitute for separate county-wide plans) 4. Establish policy and priorities for use of public funds - Links for Health (integration of Health and Behavioral Health) B. Organizational Documents / Structure ORS 190.010 - 190.110 (attaches!) - Requirements - new entity may perform any function that any party to the agreement may perform, including ORS 414.630 (fully capitated health) Limitations - members consist of governmental entities - Governing body consists of reps of partnering public agencies New entity (as distinguished from cooperative) created by ordinance Example: ABHA 2. ORS 431.414 - 431.416 (attached) - Local (District) Board of Health consisting of contiguous counties - Governing body - in addition to reps from counties, may consist of private individuals - note there are still potential ethics issues (ORS 244) - Formation process is not clear, analogous to intergovernmental agreement - Authority is limited to activities necessary for prevention of disease - Examples listed in ORS 431.416 (not fully capitated health care) - Example: North Central Public Health District (Wasco, Sherman, Gilliam) 3. Other? - May require new legislation - Simple formation process (ORS 190) - Contiguous counties (ORS 431) Page 1 of 4 L4H Health Integration Project Transitional Board June 18, 2010 - Governing body can consist of reps from private entities (ORS 431) - But still need to be aware of ethics issues - Broad scope of authority (ORS 190) - District Board of Health - ORS 431.416 - Plus - Fully capitated health care 4. Future Expansion or Contraction of authority - Fully capitated health - managed care (ORS 413 - attached) * Prescription, Lab, X-rays * Dev. Disability * Chemical Dependency - Behavioral health (currently furnished by ABHA) - Public Health * Epidemiology * Emergency Preparedness * Inspections C. Governance 1. Board - Three counties? - Three counties + - Weighted voting based upon population, funding? - To what extent will county autonomy be retained? - Focus on RHA authority being exercised 2. Advisory Board - Purely advisory - Effectively the governing body? - Composition * Three counties appoint * Partners/interest groups * Terms of office * Costs to operate * Opt-out * Location of HQ * How to add on: expiration re openness Officially established or informal (regular matter on agenda) public meetings, records, ethics, considerations 3. Administration - Entity staff - Shared staff of member county - compensation 4. Sunset, Opt-out provisions, Transition D. Allocation of Resources 1. As between three counties 2. As between source/location of services/need Page 2 of 4 1_4H Health Integration Project Transitional Board June 18, 2010 3. Region v. counties E. Legislative Needs? 1. Chap 431 adjustment? 2. Establish authority to provide basic health care to general population on part of County 3. Need to address: if current "County" requirements need to be made, "regional" may need to happen F. Information Sharinq 1. HlPAA 2. Funding driven requirements: mental health; reproductive health; institutional requirements: conditions of grants-laws-contracts 3. Establishing contractual commitments to enable information sharing G. Contractual Relationship Issues 1. Existing terms/duration: ability-desire to amend 2. State & County: State to ABHA; County to service providers 3. Transition H. Role of ABHA 1. St. Charles 2. Insurers (COINS) 3. Medical care providers 1. Models 1. Care Oregon 2. GOBHI (phonetic??) Eastern Oregon 3. Intermediate v. long term 4. ABHA J. Funding 1. State-Federal Page 3 of 4 L4H Health Integration Project Transitional Board June 18, 2010 2. County sources (how do these fit in?) - Subject to allocation consistent with regional objectives or remain local? 3. Grant v. State-Fed: Grant stays with awarded County or RHA K. Need a "Plan" 1. Who creates 2. When does it change 3. What does it cover Page 4 of 4 L4H Health Integration Project Transitional Board June 18, 2010 GOVERNMENT COOPERATION; CENSUS; ARBI'T'RATION 190.050 4r INTERGOVERNMENTAL C%J ERATION (Generally) 190.003 Definitions for ORS 190 003 t ` . o 190.130. As used in ORS 190.003 to 190.130 , "unit of local government" includes a county, city, district or other public corporation, . " commission, authority or entity organized d an existing under statute or city or county charter. [1967 c.550 §21 190.007 Policy; construction In the in . terest of furthering economy and efficiency in local government, intergovernmental co- operation is declared a matter of statewide concern. The provisions of ORS 190.003 to s 190.130 shall be liberally construed. [1967 c.550 r.. § .s . 190.010 Authority of local govern- ments to make intergovernmental agree- anent. A unit of local government may enter into a written agreement with any other unit or units of local government for the per- formance of any or all functions and activ- ities that a party to the agreement, its officers or agencies, have authority to per- form. The agreement may provide for the performance of a function or activity: (1) By a consolidated department; (2) By jointly providing for administrative officers; (3) By means of facilities or equipment jointly constructed, owned, leased or oper- ated; (4) By one of the parties for any other party; (5) By an intergovernmental entity cre- ated by the agreement and governed by a board or commission appointed by, responsi- ble to and acting on behalf of the units of local government that are parties to the agreement; or (6) By a combination of the methods de- scribed in this section. [Amended by 1953 x161 §2; 1963 c.189 §1; 1967 c.550 §4; 1991 c.583 §11 190.020 Contents of agreement. (1) An agreement under ORS 190.010 shall specify the functions or activities to be performed and by what means they shall be performed. Where applicable, the agreement shall pro- vide for: (a) The apportionment among the parties to the agreement of the responsibility for providing funds to pay for expenses incurred in the performance of the functions or activ- ities. (b) The apportionment of fees or other revenue derived from the functions or activ- ities and the manner in which such revenue shall be accounted for. Title 19 (c) The transfer of personnel and the preservation of their employment benefits. (d) The transfer of possession of or title to real or personal property. (e) The term or duration of the agree- ment, which may be perpetual. (f) The rights of the parties to terminate the agreement. (2) When the parties to an agreement are unable, upon termination of the agreement, to agree on the transfer of personnel or the division of assets and liabilities between the parties, the circuit court has jurisdiction to determine that transfer or division. (,mended. by 1967 c.550 §51 190.030 Effect of agreement. (1) When an agreement under ORS 190.010 has been entered into, the unit 'of local government, consolidated department, intergovernmental entity or administrative officer designated therein to perform specified functions or ac- tivities is vested with all powers, rights and duties relating to those functions and activ- ities that are vested by law in each separate party to the agreement, its officers and agencies. (2) An officer designated in an agreement to perform specified duties, functions or ac- tivities of two or more public officers shall be considered to be holding only one office. (3) An elective office may not be termi- nated by an agreement under ORS 190.010. [Amended by 1967 c.550 §6; 1991 x583 §21 190.040 [Amended by 1953 c.182 §2; 1957 c.428 §1; repealed by 1963 c.189 §31 190.050 Fees for geographic data; uses. (1) An intergovernmental group may impose and collect reasonable fees based on market prices or competitive bids for geographic data that have commercial value and are an entire formula, pattern, compilation, pro- gram, device, method, technique, process, da- tabase or system developed with a significant expenditure of public funds. An intergovern- mental group may enter into agreements with private persons or entities to assist with marketing such products. Notwithstanding any other provision of law, intergovern- mental group software product programming source codes, object codes and geographic databases or systems are confidential and exempt from public disclosure under ORS 192.502. Nothing in this section authorizes an intergovernmental group to restrict ac- cess to public records through inclusion of such records in a geographic database or system. (2) Fees collected under subsection (1) of this section shall be used: (a) For maintenance of the formula, pat- tern., compilation, program, device, method, technique, process, database or system; and Page 425 (2009 Edition) 190.070 MISCELLANEOUS MATTERS (b) To provide services through the for- mula, pattern, compilation, program, device, method, technique, process, database or sys- tem t0 p ublic bodiL r pay::~g a set vice charge to the intergovernmental group. (3) As used in this section, "intergovern- mental group" means two or more units of local government that have entered into a written agreement under ORS 190.010. [1991 x335 §21 190.070 Agreement changing servic responsibilities requires changes in t coordination resulting from change. (1) any agreement entered into under OR 190.010 to 190.030 or 190.110 between o among units of local government include changes in service responsibility, that agree ment shall set forth any changes in tax co ordination resulting from the change i in service responsibility. (2) This section applies to agreement entered into after September 29, 1991, and January 1, 1996. [1991 c.396 §9; 1993 c.424 §31 Note: 190.070 was enad by the tive Assembly but was otcadd dttolormade a pertlo- ORS chapter 190 or any series therein by legislative action. See Preface to Oregon Revised Statutes for fur- ther explanation. 190.080 Powers of intergovernmental entity created by intergovernmental agreement; Iiinits; debts of entity; proce- dure for distribution of assets; rules. (1) An intergovernmental entity created by an intergovernmental agreement under ORS 190.010 may, according to the terms of the agreement: (a) Issue revenue bonds under ORS chap- ter 287A or enter into financing agreements authorized under ORS 271.390 to accomplish the public purposes of the parties to the agreement, if after a public hearing -the gov- erning body of each of the units of local government that are parties to the agree- ment approves, by resolution or order, the issuance of the revenue bonds or entering into the financing agreement; (b) Enter into agreements with vendors, trustees or escrow agents for the installment purchase or lease, with option to purchase, of real or personal property if the period of time allowed for payment under an agree- ment does not exceed 20 years; and (c) Adopt all rules necessary to carry out its powers and duties under the intergovern- mental. agreement. (2) Except as provided in ORS 190.083, an intergovernmental entity may not levy taxes or issue general obligation bonds. (3) The debts, liabilities and obligations of an intergovernmental entity shall be, Title 19 jointly and severally, the debts, liabilities and obligations of the parties to the inter- governmental agreement that created the entity, unless the agreement specifically pro- vides otherwise. (4) A party to an intergovernmental agreement creating an intergovernmental entity may assume responsibility for specific debts, liabilities or obligations of the inter- ax to an intergovernmental entity shall not ac- If crue to the benefit of private persons. Upon (a) The disposition, division and distrib- (b) The assumption of any outstanding indebtedness or other liabilities of the entity f agreement that created the entity. governmental entity. e (5) Any moneys collected by or credited S dissolution of the entity, title to all assets of r the intergovernmental entity shall vest in s the parties to the intergovernmental agree- - ment. The agreement creating the entity - shall provide a procedure for: ution of any assets acquired by the intergov- ernmental entity; and by the parties to the intergovernmental (6) An intergovernmental entity created by intergovernmental agreement under ORS 190.010 may be terminated at any time by unanimous vote of all the parties to the intergovernmental agreement or as provided by the terms of the agreement. [1991 c.583 44; 2001 c.840 §3; 2003 c.195 §7; 2007 c.783 §711 190.083 County agreements for trans- portation facilities. (1) Before a county en- ters into an intergovernmental agreement creating an intergovernmental entity to op- erate, maintain, repair and modernize trans- portation facilities, the county shall obtain approval of the terms and conditions of the agreement from the governing bodies of a majority of the cities within the county. (2) Subject to the provisions of this sec- tion, an intergovernmental entity created to operate, maintain, repair and modernize transportation facilities may issue general obligation bonds and assess, levy and collect taxes in support of the purposes of the entity. (3)(a) To carry out the purposes of an intergovernmental agreement under this sec- tion, and when authorized at an election de- scribed in paragraph (b) of this subsection, an intergovernmental entity created to oper- ate, maintain, repair and modernize trans- portation facilities may borrow moneys and sell and dispose of general obligation bonds. Approval requires an affirmative vote of a majority of the electors within the intergov- ernmental entity voting in the election. (b) If the bonds are not subject to the limitations under section 11 or 11b, Article XI of the Oregon Constitution: Page 426 (2009 Edition) GOVERNMENT COOPERATION; CENSUS; ARBI'T'RATION 190.110 (A) The proposition submitted to the electors shall provide that the intergovern- mental entity shall assess, levy and collect taxes each year on the assessed value of all taxable property within the intergovern- mental entity for the purposes of paying the principal and interest on the general obli- gation bonds; (B) The election must comply with the voter participation requirements of section 11 (8), Article XI of the Oregon Constitution; and (C) Outstanding bonds may never exceed in the aggregate two percent of the real market value of all taxable property within the entity. (4) The governing body of an intergov- ernmental entity created to operate, main- tain, repair and modernize transportation facilities shall issue the bonds from time to time as authorized by the electors of the en- tity. The governing body shall issue the bonds according to the applicable provisions of ORS chapter 287A. (5) The electors of an intergovernmental entity created to operate, maintain, repair and modernize transportation facilities may 4 establish a permanent rate limit for ad valorem property taxes for the entity pursu- ant to section 11 (3)(c), Article XI of the Or- egon Constitution. 4 (6) An intergovernmental entity created to operate, maintain, repair and modernize transportation facilities may exercise the powers necessary to carry out the purposes of the intergovernmental agreement, includ- ing but not limited to the authority to enter into agreements and to expend tax proceeds . and other revenues the entity receives. (7) An intergovernmental entity created to operate, maintain, repair and modernize transportation facilities is not a district as defined in ORS 198.010 and is not subject to the provisions of ORS chapter 451. (8) An intergovernmental entity described in this section is subject to ORS 294.305 to 294.565 for each fiscal year or budget period in which the entity proposes to impose or imposes ad valorem property taxes. [2001 c.840 §2; ..003 c.14 §88; 2003 c.235 §3; 2007 083 §721 190.085 Ordinance ratifying intergov- r i ernmental agreement creating entity. (1) e.;:. Prior to the effective date of an intergovern- mental agreement creating an intergovern- mental entity, each of the parties to the intergovernmental agreement shall enact an ordinance ratifying the creation of the inter - t governmental entity. An ordinance enacted "'~a`'?` nnrlPr this cnhsPrtinn chall• (a) Declare that it is the intent of the `x governing body enacting the ordinance to create an intergovernmental entity by inter- governmental agreement; (b) Specify the effective date of the intergovernmental agreement; (c) Set forth the public purposes for which the intergovernmental entity is cre- ated; and (d) Describe the powers, duties and func- tions of the intergovernmental entity. (2) Not later than 30 days after the ef- fective date of an intergovernmental agree- ment creating an intergovernmental entity under ORS 190.010, the parties to the inter- governmental agreement shall file with the Secretary of State copies of the ordinances required under this section together with a statement containing the name of the inter- governmental entity created, the parties to the agreement, the purpose of the agreement and the effective date of the agreement. [1991 c.583 §51 190.110 Authority of units of local government and state agencies to coop- erate; agreements with American Indian tribes; exclusion of conditions for public contracts. (1) In performing a duty imposed upon it, in exercising a power conferred upon it or in administering a policy or program delegated to it, a unit of local government or a state agency of this state may cooperate for any lawful purpose, by agreement or oth- erwise, with a unit of local government or a state agency of this or another state, or with the United States, or with a United States governmental agency, or with an American Indian tribe or an agency of an American Indian tribe. This power includes power to provide jointly for administrative officers. (2) The power conferred by subsection (1) of this section to enter into an agreement with an American Indian tribe or an agency of an American Indian tribe extends to any unit of local government or state agency that is not otherwise expressly authorized to en- ter into an agreement with an American In- dian tribe or an agency of an American Indian tribe. (3) With regard to an American Indian tribe, the power described in subsections (1) and (2) of this section includes the power of the Governor or the designee of the Gover- nor to enter into agreements to ensure that the state, a state agency or unit of local government does not interfere with or in- fringe on the exercise of any right or privi- lege of an American Indian tribe or members of a tribe held or granted under any federal treaty, executive order, agreement, statute, policy or any other authority. Nothing in this subsection shall be construed to modify the obligations of the United States to an American Indian tribe or its members con- Title 19 Page 427 (2009 Edition) 431.405 PUBLIC HEALTH AND SAFETY hensive plan created pursuant to ORS 417.775. 11983 c.398 §3; 2003 c.553 §6; 2009 c.595 §5611 Note: See note under 431.375. LOCAL BOARDS OF HEALTH 431A05 Purpose of ORS 431.405 to 431.510. It is the purpose of ORS 431.405 to 431.510 to encourage improvement and standardization of health departments in or- der to provide a more effective and more ef. ficient public health service throughout the state. [1961 c.610 §11 431.410 Boards of health for counties. The governing body of each county shall constitute a board of health ex officio for each county of the state and may appoint a public health advisory board as provided in ORS 431.412 (5) to advise the governing body on matters of public health. [Amended by 1953 c.189 §3; 1961 c.610 §2; 1973 c.829 §20al 431.412 County board of health; for- mation; composition; advisory board.. (1) The governing body of any county shall es- tablish a county board of health, when au- thorized to do so by a majority of electors of the county at an y general or special election, and may, if such authorization is made, es- tablish a public health advisory board as provided in subsection (5) of this section. (2) The county board of health shall con- sist of. (a) One member of the county governing body selected by the body. (b) One member of a common school dis- trict board having jurisdiction over the en- tire county or of the . education service district board who resides in the county and is selected by the education service district board, or the designee of that member. (c) One physician who has been licensed to practice medicine in this state by the Or- egon Medical Board. (d) One dentist who has been licensed to practice dentistry in this state by the Oregon Board of Dentistry. (e) Three other members. (3) The members referred to in subsection (2)(c) to (e) of this section shall be appointed by the members serving under subsection (2)(a) and (b) of this section. The term of of- fice of each of such appointed members shall be four years, terms to expire annually on February 1. The first appointments shall be for terms of one, two, three or four years, as designated by the appointing members of the board. (4) Whenever a county board of health is created under this section, such board shall be in lieu of the board provided for in ORS 431.410. (5) The governing body of the county may, as provided in subsection (1) of this section, appoint a public health advisory board for terms of four years, the terms to expire annually on February 1. The first ap- pointments shall be for terms of one, two, three or four years as designated by the governing body. The advisory board shall meet regularly to advise the county board of health on matters of public health. The advi- sory board shall consist of (a) Persons licensed by this state as health care practitioners. (b) Persons who are well informed on public health matters. [Formerly 43L470; 1963 c.544 §49; 1977 c.582 §25; 1981 c.127 §1; 1987 c.618 §2; 1991 c.167 §26; 2003 c226 §221 431.414 District board of health; for- mation; composition; advisory board. (1) Two or more contiguous counties may com- bine for the purpose of forming a district health unit when the governing body of each of the counties concerned adopt resolutions signifying their intention to do so. (2) The governing bodies of the counties forming the district may meet together, elect a chairperson and transact business as a dis- trict board of health whenever a majority of the members of the governing bodies from each of the participating counties are present at any meeting. (3) In lieu of the procedure in subsection (2) of this section, the governing bodies of the counties forming the district may, by a two-thirds vote of the members from each participating county, establish and, except as provided in paragraph (f) of this subsection, appoint a district board of health which shall consist of. (a) One member from each participating county governing body selected by such body. (b) One member from a school adminis- trative unit within the district. (c) One member from the administrative staff of a city within the district. (d) Two physicians who have been li- censed to practice medicine in this state by the Oregon Medical Board and who are resi- dents of the district. . (e) One dentist who has been licensed to practice dentistry in this state by the Oregon Board of Dentistry and who is a resident of the district. (f) One person who is a resident of the district and who is to be appointed by the members serving under paragraphs (a) to (c) of this subsection. (4) The term of office of the members re- ferred to in subsection (3)(a) to (f) of this section shall be four years, the terms to ex- pire annually on February 1. The first ap- Title 36 Page 16 (2009 Edition) °F ~Y ADMINISTRATION OF HEALTH LAWS pointments shall be for terms of one, two, three or four years, as may be designated by two-thirds vote of the members from each participating county. (5) Whenever a district board of health is created under this section, such board shall be in lieu of the board provided for in ORS 431.410 or 431.412. (6) The governing bodies of the counties malting up the district may appoint a public health advisory board for terms of four years, the terms to expire annually on February 1. The first appointments shall be for terms of one, two, three or four years as designated by the governing body. The advisory board shall meet regularly to advise the district board of health on matters of public health. The advisory board shall consist of: (a) Persons licensed by this state as health care practitioners.- (b) Persons who are well informed on public health matters. [Formerly 431.610; 1973 c.829 §21; 1977 c.582 §26; 1987 c.618 §31 431.415 Powers and duties of local health boards; rules- fee schedules. (1) The district or county Loard of health is the policymaking body of the county or district in implementing the duties of. local depart- ments of health under ORS 431.416. (2) The district or county board of health shall adopt rules necessary to carry out its policies under subsection (1) of this section. The county or district board of health shall adopt no rule or policy which is inconsistent with or less strict than any public health law or rule of the Oregon Health Authority. (3) With the permission of the county governing body, a county board may, and with the permission of the governing bodies of the counties involved, a district board may, adopt schedules of fees for public health services reasonably calculated not to exceed the cost of the services performed. The health department shall charge fees in ac- cordance with such schedule or schedules adopted. [1961 c.610 §6; 1973 c.829 §22; 1977 c.582 §27; 2009 c.595 §5621 431.416 Local public health authority or health district; duties. The local public health authority or health district shall: (1) Administer and enforce the rules of the local public health authority or the health district and public health laws and rules of the Oregon Health Authority. (2) Assure activities necessary for the preservation of health or prevention of dis- ease in the area under its jurisdiction as provided in the annual plan of the authority or district are performed. These activities shall include but not be limited to: 431.418 (a) Epidemiology and control of preventable diseases and d ior~ u -era, (b) Parent and child health services, in- cluding family planning clinics as described in ORS 435.205; (c) Collection and reporting of health statistics; (d) Health information and referral ser- vices; and (e) Environmental health services. [1961 c.610 §8; 1973 c.829 §23; 1977 c.582 §28; 1983 c.398 §4; 2001 c.900 §150; 2009 c.595 §5631 431.418 Local public health adminis- trator; health officer; duties; salary. (1) Each district board of health shall appoint a qualified public health administrator to su- pervise the activities of the district in accor- dance with law. Each county governing body in a county that has created a county board of health under ORS 431.412 shall appoint a qualified public health administrator to su- pervise the activities -of the county health department in accordance with law. In mak- ing such appointment, the district or county board of health shall consider standards for selection of administrators prescribed by the Oregon Health Authority. (2) When the public health administrator is a physician licensed by the Oregon Med- ical Board, the administrator shall serve as health officer for the district or county board of health. When the public health adminis- trator is not a physician licensed by the Or- egon Medical Board, the administrator will employ or otherwise contract for services with a health officer who shall be a licensed physician and who will perform those spe- cific medical responsibilities requiring the services of a physician and shall be respon- sible to the public health administrator for the medical and paramedical aspects of the health programs. (3) The public health administrator shall: (a) Serve as the executive secretary of the district or county health board, act as the administrator of the district or county health department and supervise the officers and employees appointed under paragraph (b) of this subsection. (b) Appoint with the approval of the health board, administrators, medical offi- cers, public health nurses, environmental health specialists and such other employees as are necessary to carry out the duties and responsibilities of the office. (c) ' Provide the board at appropriate in- tervals information concerning the activities of the county health department and submit an annual budget for the approval of the county governing body except that, in the case of the district public health administra- tor, the budget shall be submitted to the Title 36 Page 17 (2009 Edition) ~p 7-7 P.. MEDICAL ASSISTANCE 414.640 designated to sen e on the review committee i~ the Director of the Services for Children with Special Health Needs. (2) No member of the review committee shall be held criminally or civilly liable for actions pursuant to this section provided the member acts in good faith, on probable cause and without malice. [1985 c.532 §3; 1989 c.224 §831 i4r Note: See note under 414.550. 4714.565 When payments not made for cystic fibrosis services. Payments under ORS 414.550 to 414.565 shall not be made for any services which are available to the re- cipient under any other private, state or fed- eral programs or under other contractual or `2. legal entitlements. However, no provision of ORS 414.550 to 414.565 is intended to limit in any way state participation in any federal program for medical care of persons with - cystic fibrosis. [1985 c.532 §4f Note: See note under 414.550. ' OREGON HEALTH CARE COST . CONTAINMENT SYSTEM 414.610 Legislative intent. It is the in- .;4 tent of the Legislative Assembly to develop and implement new strategies for persons el- igible to receive medical assistance that pro- mote and change the incentive structure in the delivery and financing of medical care, that encourage cost consciousness on the part of the users and providers while main taining quality medical care and that strive to make state payments for such medical 5 care sufficient to compensate providers ade- quately for the reasonable costs of such care in order to minimize inappropriate cost shifts onto other health care payers. [1983 c.590 §1; 1985 047 §31 414.620 System established. There is established the Oregon Health Care Cost Containment System. The system shall con- sist of state policies and actions that en- courage price competition among health care providers, that monitor services and costs of the health care system in Oregon, and that maintain the regulatory controls necessary to assure quality and affordable health ser- vices to all Oregonians. The system shall also include contracts with providers on a prepaid capitation basis for the provision of at least hospital or physician medical care, or both, to eligible persons as described in ORS 414.025. 11983 c.590 §2; 1985 x747 §21 414.630 Prepaid capitated health care service contracts; when fee for services to be paid. (1) The Oregon Health Authority shall execute prepaid capitated health ser- vice contracts for at least hospital or physi- cian medical care, or both, with hospital and medical organizations, health maintenance organizations and any other appropriate pub- lic or private persons. (2) For purposes of ORS 279A.025, 279A.140, 414.145 and 414.610 to 414.640, in- strumentalities and political subdivisions of the state are authorized to enter into prepaid capitated health service contracts with the Oregon Health Authority or the Oregon Health Policy Board and shall not thereby be considered to be transacting insurance. (3) In the event that there is an insuffi- cient number of qualified bids for prepaid capitated health services contracts for hospi- tal or physician medical care, or both, in some areas of the state, the Oregon Health Authority may continue a fee for service payment system. (4) Payments to providers may be subject to contract provisions requiring the retention of a specified percentage in an incentive fund or to other contract provisions by which ad- justments to the payments are made based on utilization efficiency. [1983 c.590 §3; 1991 c.66 §24; 2003 c.794 §275; 2009 c.595 §3171 414.640 Selection of providers; re- imbursement for services not covered; actions as trade practice; actions not in- surance; rules. (1) Eligible persons shall se- lect, to the extent practicable as determined by the Oregon Health Authority, from among available providers participating in the pro- gram. (2) The authority by rule shall define the circumstances under which it may choose to reimburse for any medical services not cov- ered under the prepaid capitation or costs of related services provided by or under referral from any physician participating in the pro- gram in which the eligible person is enrolled. (3) The authority shall establish require- ments as to the minimum time period that an eligible person is assigned to specific pro- viders in the system. (4) Actions taken by providers, potential providers, contractors and bidders in specific accordance with this chapter in forming consortiums or in otherwise entering into contracts to provide medical care shall be considered to be conducted at the direction of this state, shall be considered to be lawful trade practices and shall not be considered to be the transaction of insurance for pur- poses of ORS 279A.025, 279A.140, 414.145 and 414.610 to 414.640. [1983 G590 §4; 1991 c.66 §25; 2003 094 §276; 2009 c.595 §3181 414.650 [1983 c.590 §7; 1987 x660 §19; 1989 c.513 §1; 1991 c.66 §26; repealed by 1995 027 §481 414.660 [1983 c.590 §5; 1985 04.7 §3; 1991 c.66 §27; 2009 c.ll §57; repealed by 2009 c.595 §1204.1 414.670 [1983 c.590 §6; 1985 c.747 §3a; 1991 c.66 §28; repealed by 2009 c.695 §12041 Title 34 Page 617 (2009 Edition) sy _y 414.705 HUMAN SERVICES; JUVENILE CODE; CORRECTIONS SCOPE OF COVERED HEALTH SERVICES 414.705 Definitions for ORS 414.705 to 414,760. (1) As used in ORS 414.705 to 414.750, "health services" means at least so much of each of the following as are ap- proved and funded by the Legislative Assem- bly: included Einlcthe require s bm medical alaslaw to be sistance program in order for the program to qualify for federal funds; (b) Services provided by a physician as defined in ORS 677.010, a nurse practitioner certified under ORS 678.375 or other licensed practitioner within the scope of the practi- tioner's practice as defined by state law, and ambulance services; (c) Prescription drugs; (d) Laboratory and X-ray services; (e) Medical supplies; (f) Mental health services; (g) Chemical dependency services; (h) Emergency dental services; (i) Nonemergency dental services; Provider described in paragraphs services, (a) other than services to W, (k), (L and (m) of this subsection, defined by federal law that may be included in the state's medical assistance program; (k) Emergency hospital services; (L) Outpatient hospital services; and (m) Inpatient hospital services. (2) Health services approved and funded under subsection (1) of this section are sub- ject to the prioritized list of health services required in ORS 414,720. [1989 c.836 §2; 1991 c.753 §4; 2003 c.735 §1; 2003 c.810 §71 Note: 414.705 to 414.750 were the Legislative Assembly but were not add d into law b to or made a part of ORS chapter 414 or any series therein by leg- islative action. See Preface to Oregon Revised Statutes for further explanation. 414.706 Legislative approval and fund- ing of health services to certain persons. The Legislative Assembly shall approve and fund health services to the following persons: (1) Persons who are categorically needy as described in ORS 414.025 (2)(o) and (p); more than 185 percent lof the federal poverty guidelines; t (3) Persons under 19 years of age with incomes no more than 200 percent of the federal poverty guidelines who do not have federal Medicare coverage. [2oo3 c.736 §3; 2009 c.867 §371 Note: 414.706 to 414.709 were added to and made a part of 414.705 to 414.760 by legislative action but were not added to any smaller series therein. See Preface to Oregon Revised Statutes for further explanation. 414.707 Level of health services pro- vided to certain persons. (1) Persons de- scribed in ORS 414.706 (1), (2), (3) and (5) are eligible to receive all the health services ap- proved and funded by the Legislative Assem- bly. eligible Ptoso eceive he health S se414.70 are rvices de- scribed in ORS 414.705 (1)(c), (f) and (g). [2003 c,735 §4; 2009 c.595 §319; 2009 c.867 §441 Note: See note under 414.706. 414.708 Conditions for coverage for certain elderly persons, ]blind persons or persons who have disabilities. (1) A person is eligible to receive the health services de- scribed in ORS 414.707 (2) when the person is a resident of this state who: or has asdi 65 abilty as those rterms~aror is blind e defined in ORS 411.704; (b) Has a y not he exceed the standard established byt Oregon Health Policy Board; and (c) Is not covered under any public or private prescription drug benefit program. (2) A person receiving prescription drug services under ORS 414.707 (2) shall pay up to a percentage of the Medicaid price of the prescription drug established by the author- ity by rule and the dispensing fee. [2003 c.735 §11; 2005 x381 §16; 2007 c.70 §194; 2009 c.595 §3201 Note: See note under 414.706. 414.709 Adjustment of population of eligible persons in event of insufficient resources. (1) Except as provided in subsec- tion (2) of this section, if insufficient re- sources are available during a biennium, the population of eligible persons receiving health services may not be reduced below the population of eligible persons approved and funded in the legislatively adopted budget for the Oregon Health Authority for the biennium. (2) The Oregon Health Authority may periodically limit enrollment of persons de- scribed in ORS 414.708 in order to stay within the legislatively. adopted budget for he authority. [2003 c.735 §4a; 2009 c.595 §3211 Note: See note under 414.706. federal poverty guidelines; 414.710 Services not subject to prior- itized list. The foll (4) Persons described in ORS 414.708; and subject to ORS 414.720: owing services are not ears of inco(5)ePers noo more 19 than 100 age or the home) ndrs ommufacilities, nity-based waiverd se - Title 34 Page 618 (2009 Edition) ='i :a. hp MEDICAL ASSISTANCE vices funded through the Department of Hu- man Services; and (2) Services to children who are wards of the Department of Human Services by order of the juvenile court and services to children and families for health care or mental health care through the department. [1989 c.836 §3; 1991 c.67 §107, 1991 053 §5; 1993 c.815 §17; 1997 c.581 §25; 1999 c.1084 §52; 2005 c.381 §17; 2007 c.70 §195; 2009 c.595 §322; 2009 c.867 §451 Note: See note under 414.705. 414.7712 Medical assistance for certain eligible persons. The Oregon Health Au- thority shall provide medical assistance un- der ORS 414.705 to 414.750 to eligible persons who are determined eligible for medical as- sistance by the Department of Human Ser- vices according to ORS 411.706. The Oregon Health Authority shall also provide the fol- lowing: (1) Ombudsman services for eligible per- sons who receive assistance under ORS 411.706. With the concurrence of the Gover- nor and the Oregon Health Policy Board, the Director of the Oregon Health Authority shall appoint ombudsmen and may terminate an ombudsman. Ombudsmen are under the supervision and control of the director. An ombudsman shall serve as a patient's advo- cate whenever the patient or a physician or other medical personnel serving the patient is reasonably concerned about access to, quality of or limitations on the care being provided by a health care provider. Patients shall be informed of the availability of an ombudsman. Ombudsmen shall report to the Governor and the Oregon Health Policy Board in writing at least once each quarter. A report shall include a summary of the ser- vices that the ombudsman provided during the quarter and the ombudsman's recommen- dations for improving ombudsman services and access to or quality of care provided to eligible persons by health care providers. (2) Case management services in each health care provider organization for those eligible persons who receive assistance under ORS 411.706. Case managers shall be trained in and shall exhibit skills in communication with and sensitivity to the unique health care needs of people who receive assistance under ORS 411.706. Case managers shall be reasonably available to assist patients served by the organization with the coordination of the patient's health care services at the rea- sonable request of the patient or a physician or other medical personnel serving the pa- tient. Patients shall be informed of the availability of case managers. (3) A mechanism, established by rule, for soliciting consumer opinions and concerns regarding accessibility to and quality of the services of each health care provider. Title 34 414.715 (4) A choice of available medical plays and, within those plans, choice of a primary care provider. (5) Due process procedures for any indi- vidual whose request for medical assistance coverage for any treatment or service is de- nied or is not acted upon with reasonable promptness. These procedures shall include an expedited process for cases in which a patient's medical needs require swift resolu- tion of a dispute. [1991 c.753 §14; 1993 c.815 §18; 1997 c.581 §26; 1999 c.547 §7; 1999 c.1084 §53; 2003 c.14 0193,193x; 2003 c.591 §§1,2; 2005 c.381 §18; 2009 c.595 §323; 2009 c.867 §461 Note: See note under 414.705. 414.715 Health Services Commission; confirmation; qualifications; tennis; ex- penses; subcommittees. (1) The Health Services Commission is established, consist- ing of 12 members appointed by the Governor in consultation with professional and other interested organizations and confirmed by the Senate, as follows: (a) Five members must be physicians li- censed to practice medicine in this state who have clinical expertise in the general areas of obstetrics, perinatal health, pediatrics, adult medicine, mental health and chemical dependency, disabilities, geriatrics or public health. One of the physicians must be a doc- tor of osteopathy. (b) One member must be a dentist li- censed under ORS chapter 679 who has clin- ical expertise in general, pediatric or public health dentistry related to the delivery of dental. services under the Oregon Health Plan. (c) One member must be a public health nurse. (d) One member must be a social services worker. (e) Four members must be consumers of health care. (2) Members of the Health Services Commission serve for a term of four years, at the pleasure of the Governor. (3) Members are not entitled to compen- sation, but may be reimbursed for actual and necessary travel and other expenses incurred by them in the performance of their official duties in the manner and amounts provided for in ORS 292.495. Claims for expenses shall be paid out of funds available to the Oregon Department of Administrative Services for purposes of the commission. (4) The commission may establish such subcommittees of its members and other medical, economic or health services advisers as it determines to be necessary to assist the commission in the performance of its duties. [1989 c.836 §4; 1991 c.753 §12; 2009 c.469 §11 Note: See note under 414.705. Page 619 (2009 Edition) 414.720 HUMAN SERVICES; JUVENILE CODE; CORRECTIONS 414.720 Pubhe hearings; public in- lth h (b) Changes due to advancements in medical technology or new data regarding ea volvement; biennial reports on services priorities; funding. (1) The Health health outcomes. Services Commission shall conduct public (7) If a service is deleted or added and hearings prior to making the report de- no new funding is required, the commission scribed in subsection (3) of this section. The shall report to the Speaker of the House of commission shall solicit testimony and infor- Representatives and the President of the mation from advocates representing seniors, Senate. However, if a service to be added re- persons with disabilities, mental health ser- quires increased funding to avoid discontinu- vices consumers and low-income Oregonians, ing another service, the commission must representatives of commercial carriers, .rep- report to the Emergency Board to request resentatives of small and large Oregon em- the funding. ployers and providers of health care, (8) The report listing services to be pro- including but not limited to physicians li- l vided t censed to practice medicine, dentists, ora surgeons, chiropractors, naturopaths, hospi- and 414.735 to 414.750 414.705 to 414. shall remain in effect from October 1 of the talc, clinics, pharmacists, nurses and allied odd-numbered year through September 30 of health professionals. the next odd-numbered year. [1989 c.836 §4a; 1991 (2) The commission shall actively solicit x753 §6; 1991 c.916 §2a; 1993 c.754 §l; 1993 c.815 §19; 1997 2003 x735 §10; 2003 c.810 §8; 2009 c.595 §3241 245 §2 public involvement in a community meeting to build a consensus on the values to ; x Note: 414.720 was added to and made a part of d dd process uide health resource allocation d to b e ORS chapter 414 by legislative action but was not a on to Ore f P g e use g ace re to any smaller series therein. See decisions. Revised Statutes for further explanation. (3) The commission shall report to the .414.721 Federal approval for funding Governor a list of health services ranked by services with assessments. The Oregon priority, from the most important to the least Health Authority shall promptly seek federal important, representing the comparative ben- approval necessary to obtain federal financial efits of each service to the entire population participation in the costs of programs and to be served. The list submitted by the coin- services funded with assessments paid under ; - mission pursuant to this subsection is not ORS 743.951 and 743.961 and section 9, { subject to alteration by any other state chapter 867, Oregon Laws 2009. [2009 x867 §16; agency. The recommendation may include practice guidelines reviewed and adopted by 2009 c.828 §50) Note: 414.721 was added to and made a part of the commission pursuant to subsection (4) Of 414305 to 414.750 by legislative action but was not this section. added to any smaller series therein. See Preface to Or- on Revised Statutes for further explanation. e (4) In order to encourage effective and efficient medical evaluation and treatment, g 414.725 Prepaid managed care health orting; cial re fi t f the commission: p nan s; services contrac males. (1)(a) Pursuant to rules adopted by the (a) May include clinical practice guide- the authority shall Oregon Health Authority, -Y, in its prioritized list of services. The execute prepaid managed care health ser- commission shall actively solicit testimony vices contracts for health services funded by and information from the medical community the Legislative Assembly. The contract must and the public to build a consensus on clip- require that all services are provided to the ical practice guidelines developed by the extent and scope of the Health Services ks commission. (b) Shall consider both the clinical effec- Commission's report for each service pro- vid.ed under the contract. The contracts are 7 B tiveness and cost-effectiveness of health ser- , 9 not subject to ORS chapters 279A and 2 290 and 279A t f vices in determining their relative eer-reviewed medical lit- i t . o except ORS 279A.250 279B.235. Notwithstanding ORS 414.720 (8), ` kAx` ng p ance us impor the rules adopted by the authority shall es- erature as defined in ORS 743A.060. tablish timelines for executing the contracts `a port described in this paragraph. by July 1 of the year preceding each regular (b) It is the intent of ORS 414.705 to session of the Legislative Assembly and shall 750 that the state use, to the greatest 414 submit a copy of its report to the Governor, . extent possible, prepaid managed care health the Speaker of the House of Representatives services organizations to provide physical . and the President of the Senate. health, dental, mental health and chemical -f~ (6) The commission may alter the list dependency services under. ORS 414.705 to , during interim only under the following con- 414.750. ditions: (c) The authority shall solicit qualified (a) Technical changes due to errors and providers or plans to be reimbursed for pro- omissions; and viding the covered services. The contracts s Title 34 Page 620 (2009 Edition) l` MEDICAL ASSISTANCE may be with hospitals and medical organiza- tions, health maintenance organizations, managed health care plans and any other qualified public or private repaid managed care health services organization. The au- thority may not discriminate against any contractors that offer services within their providers' lawful scopes of practice. (d) The authority shall establish annual financial reporting requirements for prepaid managed care health services organizations. The authority shall prescribe a reporting procedure that elicits sufficiently detailed information for the authority to assess the financial condition of each prepaid managed care health services organization and that includes information on the three highest executive salary and benefit packages of each prepaid managed care health services organ- ization. l (e) The authority shall require compli- s ance with the provisions of paragraph (d) of this subsection as a condition of entering into a contract with a prepaid managed care health services organization. (f)(A) The authority shall adopt rules and procedures to ensure that a rural health i th id h l h i li c n c at prov es a ea t serv ce to an _ enrollee of a prepaid managed care health services organization receives total aggregate payments from the organization, other payers R on the claim and the authority that are no less than the amount the rural health clinic :f would receive in the authority's fee-for- service payment system. The authority shall issue a payment to the rural health clinic in r accordance with this subsection within 45 days of receipt by the authority of a com- pleted billing form. (B) "Rural health clinic," as used in this paragraph, shall be defined by the authority by rule and shall conform, as far as practi- cable or applicable in this state, to the defi- nition of that term in 42 U.S.C. 1395x(aa)(2). (2) The authority may institute a fee-for- service case management system or a fee- for-service payment system for the same physical health, dental, mental health or chemical dependency services provided under the health services contracts for persons eli- gible for health services under ORS 414.705 to 414.750 in designated areas of the state in which a prepaid managed care health ser- vices organization is not able to assign an enrollee to a person or entity that is prima- rily responsible for coordinating the physical health, dental, mental health or chemical de- pendency services provided to the enrollee. In addition, the authority may make other special arrangements as necessary to in- crease the interest of providers in partic- ipation in the state's managed care system, including but not limited to the provision of Title 34 414.727 stop-loss insurance for providers wishing to limit the amount of risk they wish to under- write. (3) As provided in subsections (1) and (2) of this section, the aggregate expenditures by the authority for health services provided pursuant to ORS 414.705 to 414.750 may not exceed the total dollars appropriated for health services under ORS 414.705 to 414.750. (4) Actions taken by providers, potential providers, contractors and bidders in specific accordance with ORS 414.705 to 414.750 in forming consortiums or in otherwise entering into contracts to provide health care services shall be performed pursuant to state super- vision and shall be considered to be con- ducted at the direction of this state, shall be considered to be lawful trade practices and may not be considered to be the transaction of insurance for purposes of the Insurance Code. (5) Health care providers contracting to provide services under ORS 414.705 to 414.750 shall advise a patient of any service, treatment or test that is medically necessary but not covered under the contract if an or- dinarily careful practitioner in the same or similar community would do so under the same or similar circumstances. (6) A prepaid managed care health ser- vices organization shall provide information on contacting available providers to an enrollee in writing within 30 days of assign- ment to the health services organization. (7) Each prepaid managed care health services organization shall provide upon the request of an enrollee or prospective enrollee annual summaries of the organization's ag- gregate data regarding: (a) Grievances and appeals; and (b) Availability and accessibility of ser- vices provided to enrollees. (8) A prepaid managed care health ser- vices organization may not limit enrollment in a designated area based on the zip code of an enrollee or prospective enrollee. [1989 c.836 §6; 1991 c.753 §8; 2003 c.14 §194; 2003 c.735 §13; 2003 c.794 §277; 2003 c.810 §4; 2005 c.806 §8; 2007 c.458 §1; 2009 c.595 §325; 2009 c.795 §31 Note: Section 4, chapter 795, Oregon Laws 2009, provides; Sec. 4. The amendments to ORS 414.725 by section 3 of this 2009 Act apply to claims billed by a rural health clinic to a prepaid managed care health services organization on or after May 17, 2011. [2009 c.795 §41 Note: See note under 414.705. 414.727 Reimbursement of rural hos- pitals by prepaid managed care health services organization. (1) A prepaid man- aged care health services organization, as defined in ORS 414.736, that contracts with the Oregon Health Authority under ORS Page 621 (2009 Edition) Pagel of 8 Chapter 440 - Health Districts; Port Hospitals 2009 EDITION HEALTH DISTRICTS; PORT HOSPITALS PUBLIC HEALTH AND SAFETY HEALTH DISTRICTS 440.305 District created coterminous with each district existing on July 2, 1957; districts existing on July 2, 1957, abolished 440.310 New district succeeds to and replaces abolished district 440.315 Definitions for ORS 440.315 to 440.410 440.320 Health districts authorized 440.325 Board of directors; qualifications 440.327 First board of directors; how first terms computed; oath; terms; vacancy 440.330 Number of directors; terms; effect of absence; district employee not eligible to serve on board 440.335 Election of officers of board of directors; duties; quorum 440.340 Directors; meetings; rules 440.345 Position numbers for election of directors 440.347 District elections 440.350 Call of special elections 440.360 Powers of health districts 440.365 User charges 440.370 Eminent domain 440.375 Authority to issue bonds 440.380 Bonds; maturity; interest; conditions 440.385 Pledge of income and revenues to secure payment of bonds 440.390 Issuance of bonds i Page 2 of 8 , 7/6/')nI n 440.395 Tax levies; use; extension; collection; default 440.397 Filing of boundary change 440.400 Expenditure and accounting of district funds 440.403 Adoption of health district budget 440.405 District records open to inspection; preservation of records 440.410 Annual audit 440.420 Medicaid Upper Payment Limit Account PORT HOSPITALS 440.505 Port hospitals; levy of taxes; property exempt from taxation 440.010 [Amended by 1963 c.607 § 1; 1967 c.613 § 1; repealed by 1981 c.45 § 1] 440.020 [Amended by 1967 c.613 §2; repealed by 1981 c.45 § I] 440.030 [Amended by 1963 c.607 §2; 1967 c.613 §4; repealed by 1981 c.45 § I] 440.040 [1967 c.613 §3; repealed by 1981 c.45 §1] i 440.110 [Repealed by 1981 c.45 § I] 440.120 [Repealed by 1981 c.45 § I] 440.130 [Repealed by 1981 c.45 § I] 440.140 [Repealed by 1981 c.45 §1] 440.150 [Repealed by 1981 c.45 §1] 440.160 [Repealed by 1981 c.45 §1] 440.170 [Repealed by 1981 c.45 §1] 440.180 [Amended by 1967 c.317 §1; repealed by 1981 c.45 §1] 440.190 [Repealed by 1981 c.45 §1] 440.200 [Amended by 1967 c.317 §2; repealed by 1981 c.45 § I] 440.210 [Repealed by 1981 c.45 §1] 440.220 [Amended by 1963 c.607 §3; repealed by 1981 c.45 §1] 440.230 [Repealed by 1981 c.45 §1] httn://www.leg-.gtate.or.iiq/or-,/440.htm] Page 3 of 8 HEALTH DISTRICTS 440.305 District created coterminous with each district existing on July 2, 1957; districts existing on July 2, 1957, abolished. (1) There hereby is created a health district territorially coterminous with each health district existing on July 2, 1957, if such existing health district was at that time a valid health district but for the fact that the electors of the district were required to have resided in the district for a period of not less than 90 days next preceding an election. In determining the boundaries of health districts created by this subsection, full effect shall be given to annexations effected by health districts prior to November 22, 1957, under ORS 441.205 to 441.410 (1957 Replacement Part). (2) Health districts created by subsection (1) of this section are subject to and shall be governed by ORS 440.315 to 440.410. (3) Health districts territorially coterminous with health districts created by subsection (1) of this section hereby are abolished. [Formerly 441.195] 440.310 New district succeeds to and replaces abolished district. Each health district created by ORS 440.305 (1) shall in all respects be the successor of and replace the territorially coterminous health district abolished by ORS 440.305 (3). Without limiting the foregoing: (1) A successor health district is: (a) The owner of all assets of the succeeded health district, including real and personal property, money, water, water rights and riparian rights. (b) Successor party to the contracts of the succeeded health district. (c) Successor party to court proceedings in which the succeeded health district was a party. (d) Successor obligor and subject to the indebtedness, bonded or otherwise, of the succeeded health district. (2) A successor health district shall levy and collect any tax lawfully assessed or collect any tax lawfully assessed and levied, as the case may be, by the succeeded health district. (3) The rules and regulations of the succeeded health district are the rules and regulations of the successor health district until changed under ORS 440.315 to 440.410. (4) The directors and officers of the succeeded health district are the directors and officers of the successor health district. [Formerly 441.200; 1987 c.158 §84] 440.315 Definitions for ORS 440.315 to 440.410. As used in ORS 440.315 to 440.410, unless the context requires otherwise: (1) "County board" means the county court or board of county commissioners, as the case may be, of the county in which a district, or the greater portion of the taxable assessed value thereof, is located. (2) "County clerk" means the county clerk of the county in which a district, or the greater portion of the taxable assessed value thereof, is located. (3) "District board" or "board" means the board of directors of a district. (4) "Health district" or "district" means any district formed pursuant to ORS 440.315 to 440.410. (5) "Owner" means the holder of the record title to real property or the vendee under a land sale contract, if there is such a contract. [Formerly 441.205; 1975 c.701 §1; 1983 c.83 §85] 440.320 Health districts authorized. (1)(a) Health districts may be formed for the purposes of: (A) Providing clinically related diagnostic, treatment and rehabilitative services on an inpatient or outpatient basis; (B) Providing outreach programs in health care education, health care research and patient care; (C) Serving as a resource for health care providers in the district; and (D) Promoting the physical and mental health and well-being of district residents. (b) Health districts may consist of territory in one or more counties, or of a city with or without Page 4 of 8- unincorporated territory. A city shall not be divided in the formation of a health district. (c) A health district may provide services to persons residing outside its boundaries. A health district may provide services within the boundaries of another health district only with the written permission of that health district. (2) A health district may include within its boundaries all or any part of the territory of a port district organized under ORS chapter 777 if the port district does not then operate a hospital. [Formerly 441.210; 1999 c.630 § 1; 2003 c.802 § 112] 440.325 Board of directors; qualifications. The power and authority given to health districts, except as otherwise provided by ORS 440.315 to 440.410, is vested in and shall be exercised by a board of directors each of whom shall be an elector of the district. [Formerly 441.280; 1979 c.520 §1; 1983 c.83 §86; 1983 c.350 §255; 1983 c.699 §5] 440.327 First board of directors; how first terms computed; oath; terms; vacancy. (1) At the election for the first board of directors, five directors shall be elected. Their terms shall commence on the 30th day after the election. The terms of the candidates for the first board of directors who receive the first and second highest number of votes expire June 30 next following the second regular district election. The terms of the candidates who receive the third, fourth and fifth highest votes expire June 30 next following the first regular district election. (2) Not later than the 10th day after the issuance of the order of formation, the directors of the first board shall take and subscribe an oath of office and then meet and organize. (3) Except as provided in subsection (1) of this section, the term of a director is four years. (4) The board of directors shall fill any vacancy on the board as provided in ORS 198.320. [1983 c.350 §257] 440.330 Number of directors; terms; effect of absence; district employee not eligible to serve on board. (1) The board of directors of a district, by resolution offered and adopted at any regular meeting of the board, may increase the number of directors from five to no more than 15. (2) If the number of directors is increased by action of the board, the board shall not fill by appointment any newly created position on the board, but shall provide for the election at the next regular district election of a sufficient number of additional directors to fill the newly created positions on the board. (3) The term of office of each director elected under subsection (2) of this section shall begin July 1 following the next regular district election. (4) The directors who are elected under subsection (2) of this section shall determine by lot the length of term each shall hold office. The terms of not more than one-half of the directors who are appointed or elected shall expire June 30 next following the first regular district election after the appointment or election. The terms of the remainder shall expire June 30 next following the second regular district election after the appointment or election. (5) The term of a director shall expire when the director is absent from four or more consecutive regular meetings of the board and the board declares the position vacant. The vacancy shall be filled as provided by ORS 198.320 (1) and (2). (6) An individual who is an employee of a health district is not eligible to serve as a director of the health district by which the individual is employed. [Formerly 441.285; 1979 c.520 §3; 1981 c.508 §1; 1983 c.350 §258; 1983 c.699 § 1 a; 1989 c.478 §1] 440.335 Election of officers of board of directors; duties; quorum. (1) The directors of a health district shall, at the time of their organization, choose from their number a chairperson, a secretary and a treasurer, who shall hold their offices until their successors are elected and qualified. l (2) These officers shall have, respectively, the powers and shall perform the duties usual in such cases. httn://www.leg_state.or.rns/nr-,/44n html Page 5 of 8 (3) A majority shall constitute a quorum to do business and, in the absence of the chairperson, any other member may preside at any meeting. [Formerly 441.290; 2007 c.71 § 124] 440.340 Directors; meetings; rules. The district board shall hold meetings at such time and place within the district as it may, from time to time, determine, but it shall hold at least one regular meeting in each month on a day to be fixed by it, and may hold special meetings under such rules as it may make. [Formerly 441.295] 440.345 Position numbers for election of directors. (1) Each office of director of a health district shall be designated by number as Position No. 1, Position No. 2 and so forth. (2) The secretary of a district shall assign a position number to each office on the board. The secretary shall certify the number so assigned to the director in office holding that position and shall file one copy of the certification in the records of the elections officer for the district. [Formerly 441.305; 1983 c.350 §259] 440.347 District elections. (1) ORS chapter 255 governs the following: (a) The nomination and election of directors. (b) The conduct of district elections. (2) The electors of a district may exercise the powers of the initiative and referendum regarding a district measure, in accordance with ORS 255.135 to 255.205. [1983 c.350 §261] 440.350 Call of special elections. The board, at any regular meeting, may call a special election of the electors of the district. [Formerly 441.305] 440.355 [Formerly 441.315; repealed by 1979 c.190 §431] 440.360 Powers of health districts. A health district has all powers necessary to carry out the purposes of ORS 440.315 to 440.410, including, but not limited to, the power: (1) To provide directly or indirectly any physical or mental health related service. (2) To make any contract or agreement, to purchase and lease real and personal property, to enter into business arrangements or relationships with public or private entities and to create and participate fully in the operation of any business structure, including the development of business structures and arrangements for health care delivery systems and managed care plans. (3) To participate in community sponsored health screening, prevention, wellness, improvement or other activities that address the physical or mental health needs of district residents. Such participation may include clinical, financial, administrative, volunteer or other support considered appropriate by the board. (4) To perform any other acts that in the judgment of the board are necessary or appropriate to accomplish the purposes of ORS 440.315 to 440.410. [Formerly 441.320; 1979 c.520 §2; 1981 c.508 §3; 1983 c.699 §2; 1983 c.740 §155; 1985 c.747 §50; 1987 c.850 §1; 1997 c.857 §1; 1999 c.630 §2; 2003 c.802 § 113] 440.365 User charges. A health district is authorized to charge persons who use district facilities and services. [Formerly 441.325; 1999 c.630 §3] 440.370 Eminent domain. A health district may exercise within its boundaries the power of eminent domain and may purchase, sell, condemn and appropriate real property, water, water rights and riparian rights. [Formerly 441.330; 2003 c.802 §114] 440.375 Authority to issue bonds. (1) For the purpose of carrying into effect the powers granted by ORS 440.315 to 440.410, a health district, when authorized at any properly called election held for that Page 6 of 8, purpose, may borrow money and sell and dispose of general obligation bonds. (2) If prior to April 1, 1983, a health district had outstanding indebtedness incurred pursuant to ORS 440.360 (1)(k) (1997 Edition), a health district may issue general obligation bonds pursuant to this section in an amount not to exceed the unpaid principal of and interest on such indebtedness plus costs incidental to the bonds to be sold. (3) The general obligation bonds outstanding at one time shall never exceed in the aggregate two and one-half percent of the real market value of all taxable property within the district, computed in accordance with ORS 308.207. (4) Notwithstanding the provisions of subsection (3) of this section, if the district has within its limits a population of 300 or over, it shall be permitted to have bonds outstanding in an amount which shall not exceed in the aggregate 10 percent of the real market value. (5) The bonds shall be issued from time to time by the district board in behalf of the health district as authorized by its electors. [Formerly 441.335; 1983 c.191 § 1; 1991 c.459 §399; 1997 c.857 §2; 1999 c.630 §4] 440.380 Bonds; maturity; interest; conditions. (1) The bonds shall mature serially within not to exceed 30 years from issue date. (2) The bonds shall bear such rate of interest as the district board shall determine. (3) The bonds shall be so conditioned that the health district agrees therein to pay to the bearer, at a place named, the principal sum of the bonds with interest at the rate named, payable semiannually in accordance with the tenor and terms of the interest coupons attached. [Formerly 441.345; 1977 c.188 §3; 1981 c.94 §36; 1983 c.347 §27; 2001 c.215 §5] 440.385 Pledge of income and revenues to secure payment of bonds. (1) For the purpose of additionally securing the payment of the principal of and interest on general obligation bonds issued under ORS 440.375, a health district may, by resolution of the district board, which resolution shall constitute part of the contract with the holders of such general obligation bonds, pledge all or any part of the net income or revenue of its properties. (2) The district board may adopt such a resolution without submitting the question of such pledge to electors of the health district. [Formerly 441.350] 440.390 Issuance of bonds. All general obligation bonds issued under ORS 440.375 shall be issued as prescribed in ORS chapter 287A. [Formerly 441.355; 2007 c.783 § 185] 440.395 Tax levies; use; extension; collection; default. (1) Any health district may assess, levy and collect taxes not to exceed one-fourth of one percent (0.0025) of the real market value of all taxable property within the district, computed in accordance with ORS 308.207. The proceeds of such taxes shall be applied by it in carrying out the objects and purposes provided in ORS 440.320. (2) A health district, each year, may also assess, levy and collect a special tax upon all such property, real and personal, in an amount sufficient to pay the yearly interest on bonds theretofore issued by the district and then outstanding, together with any portion of the principal of such bonds maturing within such year. The special tax shall be applied only in payment of interest and principal of bonds issued by the health district, but the district may apply any funds it may have toward the payment of principal and interest of any such bonds. (3) All taxes needed shall be levied and returned to the county officer whose duty it is to extend the tax roll by the time required by law for city taxes to be levied and returned. (4) All taxes levied by a health district shall become payable at the same time and be collected by the same officer who collects county taxes. The proceeds of the taxes collected under this section shall be turned over to the health district according to law. i (5) The county officer whose duty it is to extend the county levy shall extend the levy of the health district in the same manner as city taxes are extended. httD://www.lesi.state.or.us/ors/440.htmI Page 7 of 8 (6) Property is subject to sale for the nonpayment of taxes levied by the health district in like manner and with like effect as in the case of county and state taxes. [Formerly 441.360; 1991 c.459 §400; 2001 c.215 §6] 440.397 Filing of boundary change. For purposes of ad valorem taxation, a boundary change must be filed in final approved form with the county assessor and the Department of Revenue as provided in ORS 308.225. [2001 c.138 §28] 440.400 Expenditure and accounting of district funds. (1) Except as otherwise provided by subsections (3) and (4) of this section, all money of a health district shall be deposited in one or more depositories, as defined in ORS 295.001, as designated by the district board. It shall be withdrawn or paid out only when previously ordered by resolution or vote of the board, and upon checks signed as provided by subsection (2) of this section. Receipts or vouchers, showing clearly the nature and items covered by each check drawn, shall be kept on file. (2) Except for checks issued in accordance with subsection (3) of this section, checks of a district shall be signed: (a) By the treasurer and countersigned by the chairperson, or in the absence or inability of the chairperson to act, by the secretary; or (b) By an administrative employee of the district designated by the board of directors, and countersigned by a director of the district. (3) The district board may, by resolution: (a) Set aside specified amounts from money available for operating the district hospital facility; and (b) Delegate to an administrative officer of the district in charge of the hospital facility the authority to approve specified claims for expenses previously authorized by the board and to issue and sign checks in payment thereof. (4) Moneys of a health district may be invested as provided by ORS 294.035 and 294.040. [Formerly 441.365; 1983 c.699 §3; 2001 c.215 §7] 440.403 Adoption of health district budget. (1) A health district shall adopt an annual budget by: (a) Preparing a proposed budget for the fiscal year not later than June 1 of each year; (b) Publishing a notice of the proposed budget and of the date and place of a hearing on the proposed budget five to 30 days prior to the hearing; (c) Holding a public hearing on the proposed budget; (d) Adopting a final budget by resolution not later than June 30 of each year; and (e) Filing a written notice pursuant to ORS 310.060 not later than July 15 of each year if the district seeks to impose property taxes. (2) A health district may adopt a supplemental budget by resolution at a regular meeting of the district board. A supplemental budget may not extend beyond the end of the fiscal year during which it is submitted. (3) As used in this section: (a) "Budget" means a plan of financial operation embodying an estimate of expenditures for a given period or purpose and the proposed means of financing the estimated expenditures. (b) "Fiscal year" means the period beginning on July 1 of any year and ending on June 30 of the next year. (c) "Publish" means giving notice or making information or documents available to members of the general public by printing the notice, information or documents in one or more newspapers of general circulation within the jurisdictional boundaries of the health district. [2001 c.251 §2] 440.405 District records open to inspection; preservation of records. (1) All the proceedings of the district board shall be entered at large in a record book. (2) All books, maps, plans, documents, correspondence, vouchers, reports and other papers and Page 8 of 8. ' records pertaining to the business of the health district shall be carefully preserved and shall be open to inspection as public records. [Formerly 441.370] 440.410 Annual audit. An annual audit of the district shall be made by an auditor. A true and complete copy of the auditor's report of such audit shall be filed in the office of the county clerk of the principal county, as defined by ORS 198.705, and shall remain a public record therein. [Formerly 441.375] 440.420 Medicaid Upper Payment Limit Account. (1) The Medicaid Upper Payment Limit Account is established in the State Treasury separate and distinct from the General Fund. Moneys in the account are continuously appropriated to the Oregon Department of Administrative Services for health- related programs. (2) The Oregon Health Authority shall transfer to the Medicaid Upper Payment Limit Account that portion of the payment received by the authority from health districts in this state under the Proportionate Share Incentive Adjustment State Plan Amendment to the State Medicaid Plan and under intergovernmental agreements with the health districts that is attributable to the federal funds portion of the total payment made by the authority to the health districts during the biennium. [2001 c.405 § 1; 2009 c.595 §718] PORT HOSPITALS 440.505 Port hospitals; levy of taxes; property exempt from taxation. (1) A port may construct, maintain and operate hospitals within its boundaries, subject to the provisions and limitations upon indebtedness of the port imposed by law. However, after June 23, 1967, a port may not construct or acquire a hospital if any part of a health district organized pursuant to ORS 440.315 to 440.410 lies within the boundaries of the port. (2) Should any port district under authority of subsection (1) of this section after August 20, 1957, construct, maintain and operate a hospital or hospital facilities and levy a tax for any indebtedness or other expense incurred therefor, all taxable property in the port district and also within a health district then operating hospital facilities shall be exempt from all taxes levied by a port district for such hospital purposes. [Formerly 441.505; 2003 c.802 § 115] htti)://www.leiz.state.or.us/ors/440-htmi L Q~ L O C) U c°~I C 4 O L fn 0 co W N c C L C I... 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E Q c ° O to c o as Q) O •L N o a Q O m 0) -O R 0 a O .C Y L 3= Ln c s 0 o v .L v In +r N N +J U L L] - > C2 4 = S E O 'B L CL 0 - b0 0 U m Q .c c E c M a O } L- m L- O M a4~ u V-4 a~+ o . a - - C 0) v u L s ° 3 r4 ° CLO c E v c H M co 0- N CL O -0 40- a) o 3 VI c L > O U t o cu Y V) io o -0 y w L Q a 3 (v 3 00 1 c O 7 3 o c w v o L> Q1 4, W a> i s U u m 0 (u :t v a~ x o °J ac, m° O v o L- -a a 'Eb CO m a w v E~ s > x 42 U s O Q tN w E Q Y w x o E 4 m o co a 0) no c 3= , V) -0 a o 41 N `1 to U m 10- w N •N 4v-_, ~ c0 41 in tA w E Y O m o ai > -0 t Q 00 i B N v U -a r 0 m 0 v OJ C U m 7 X cr m m O x 41 Q) U L Cl) a (U w - LL V Q~ CJ M 4 E 4- 0 m - A _ L 0 v 6 p co to U W L- a) 1 -0 "O O +U' C E O 5 C N V)4- C W N d Q 7 Q U Q O m 0- 0 • • O c O M > M V, -a ~ C m v > E O Q~ U O L C Cl, H N L 0 cv CU 0 0 +1 V, 0L u v U m to m v O U 0 u C cli a) N c C E 3 to 0 y (IJ u N c o f -0 _ ~ o + O c M e0 3 cu o 0 4) ' i - Q 0+ O E 2 0 c ai OU E O+ O j 0 0 i11 a > C 3 N m 6 c 0'o 3 c- 0J ' 'a E V, 4- m U o 4, m c 0 _ E v v O O C 0) 00 L 3 4- O 0 v U ca O U E X Q m c i o X E c 0 4- in U 0 ' a co Q •c ai c a) H M O Q O- m to •E C: 4- O 0 E c 4J - t c j N f0 C E O I~ Q Q C H f 0 ca c c y txo Q E OJ a~ ro .c M of -0 4! 14 m M o U O a m (U > L f0 N 0J 0 0 u W LA M a 40 o i 0 -0 c 0- Q_ O - 0 C 41 m X O w Lj V) "p _ M .i Q a) Nom- -0 O, ~ C i= 3 ~ u Q) ~ o m ~ vE g m "oN " - J+ M E E T ~ , - L O OJ L R L C M _g- 1., O N O c • f° , + m o 5 i L a S ~ 3 Y v m a) E Q) V) C 0--a aj C i 4, Ln E 4- a) Q) 0 L a U o O 01 a-, U aJ U Itt > N 0J O 01 o + Q C ~ O X cu u cu v> :8 -a o a~ 3 a~ E v u _ O C- o f- Q CL a, a= U- vi (n a w Q i m v N a s o fO F- S O O v v4-- o cv E E cn W N E- a, m • • • • • • • • m 0) txo V) \ m = y = O CL = O m a H O i e 0' - c 0 U a x E a w M L O Q L tQ N C O O L U 0 V Q . cc O N 4) t3l= L .Q 4a o%- 0 V N es V ~ i = ~ r N ~ C ~ C ~ tt: R ~C N K V W L N 102 N ,0 C ~ O v ~ •Q. a° E~ C d O= 0 _ L 0 Oo C ^y O i d ~ N 0 ~ m s M d L d LL C m i~ Vf a 0 Q' 0. Qa M 0 C C S 3 LL 0 C ~ 4 a) ~ o E i y .Q ~ 0 L ~ o N .L 0 ~ L VI , = + E co V v p p a 4- a~ N L v a) v ca L E m a1 a1 41 Q) O C CU tM fD (U a) -C N p "0 N W - C L N M a) a "0 a) .C E a' • N y t' a) O p iN C ^ CO E N bA C c o o OA -a s a) vi 0 = p L 2 ns p 0 4- L cu aj v a) 0 N V) 0 1 +1 O O CA N E m f6 d a-+ f0 N L V p V a) ~p a) C , to a) L 3: CU (V = -0 15 s O oA a1 -0 LO p 0 N a) > 4~ r E t N 01 a) ' N ' O to ± Q. 3 - v Q- E N w a) a A> a E a) M N j L CT o m a c = o x L a) - 110 O a- E ' o c o = D- m 0 o = W 0 c V C O -0 .o C L N 'F., a ao ~ , '6 cC a~ > m O N 'Ui O~ • O C M , N N _0 L. = ~ a p v ) o 4- a) U 4-+ a 1 2 a1 O C o N a`, v - 5; 'n CL N to Y a N > a) > O "O 2 C co 1]A Ln s X 4~ n3 CL 4- E C a) N - Q) X !d O> E ° O X ° m _ m o m LL a c u a Z ; V) a) • • • V) 4- l i 4~ (7 = a) cc o y u f 01 ° t > a ` 0 C a) a) 3 00 b-0 a) c 4- a) 4- 4-; CY C C14 ° CD V, > o O C f ti4 - > 7 u.. a) O U X O o Q E N 4J r-I O ° O a- a) CO o a) V c M v s V c CL a) a) 1 C o N E ~ a) N 3 W OL X X -0 a) p ° a) > a) a) N m 0 C Co L ~ o to a) v > a) E E o o w m +1 a to U E v ' ` 't a) a C o E N ~ ~ o M m N c 3 w E X V) > 4 O C • - c 3 o E o a Q = v > f6 > O .O L a) t V O C 2 - a) m a) N v a a) E m c lD ` O O N V ° E a N 4- ~ 4 -0 p ~a ~ a) E O O C M O ) O 4- aJ 7 N L C O Q N O a a) p N a) a) Q Y N w y w +J Q) Q N H: N L m O E E C M v .C C is a o cLa 3 E E a) 0 m f 6 ~o n > a) L u 4-1 a) E a) N N v a) Co a ar- E .r -0 o a) 0 E o to v E v a, a) i N O a) C a) N a) .L E te L O O r a C Q V rv vi L v y- > ~O to L p Q V V C - v 3 o a v E v 3 Y 'o O aaj o o- o E •E E 4 2 O a ) a C L ±o E O a i Q) N p > 0 Q 0 0 L) p p v a) m ca o ~ N ca - O E 4 E a 0 -D N E ~o c N L 3 > a O - 4-1 v c v L v o N a) 3 O O m a) L N X cu ~ > f6 L E W a > N W O -a X Q V, w . LA E -0 C E v ~ v aj O° v av) a) E a) E a; o Q) ° 0 0 N to to o 0 o a ° a o 0 0 o M o o v f° c o o E C'4 ) g O o E o Ln a 'X C a a) N v N ~ a a a a E ~ o U ti4 L a o W W > m = 0 N E X E V w ro ° w v w + ° C L a 0 0 o a E o w m z L of w m to ar ~ G N N a° ao 0 M 0 o a Q- > L- E N W i N 'C N L It 0 L Q L f6 N O M m L L cs U 0 N N O V V Q O 04 L Q ~a O p U N C cu 13 c Lo C ~ t4 N K V W L N N 'a C O O ~ V v - o CL a Er O= t~ 0 am 00- 0 c E d ~ N d ~ m s cts 2 d C a) O f0 O O i O 0 7 O O ~ ut I VI i > v L C o f 6 = O f0 O L O O C L ' a o o Ln W w -0 = on v -r o E L an t a) U u 0 c- :3 C t CL Q a) CL W N . w a) o 4- r r- v, 'In O ca O co c c to °w-' > to ° a M t/? W ° ca ti O -a fB - O o 3 o o 3 o O o > 0) U LJ v ti0 Y M al L a) a1 i O In O = o O ~ v * = v v0 - c O - Vf M U (A E co 41 0 a + v V) = 3 0n c a~ y > c o on a, c en = a, c ; a) a a) L co :E u E E a) v i 0 ' pq LA (O v 'p L Y °1 co = ° L $ -a \ m a bn = _ 3 Y = of v 4- O ° c0 x = L s a o f6 L a . a) o = n a) v " -a 3: uj Q al L O (A c o O a , a a) c a ' = o a L Q- a v e p c a _ U E O = E _ E = CL v E 0 = u 0 a) +r = rn • o E v E c m W 3 = _ co = V) E . r = - n) u c ° v; U 4 - O L Z E O .L Q .L Q. o o L O O ra C . ro ~ 3 L C !n O C O N y 'V1 O N 3 E 7 Q f0 > _ 0A L L 0A ~ o > ~ _ O w v E = O M E 4-1 a) w H = co N to v 0n v L Q LL to a1 O O v C M cn 04 > a N w . 2 a 4? 0 ° ° ,1 cD O E E O co E c v v w a W 4- O M Ln 3 o E a to E + W ~ E V1 L y o U O - L L `o o = E 0 0 al U -C 4- to 3 ~ t x O v = o L ? ' ~ ro U 0 4- c L N a) o a, > - E = a, = ca L s 0 v I- co a) co c0 O =3 In a) 4, o a, o 0 0n Ln o > o -a n o a .3 t E a o o m w a L E~ .v L m a) 3 o ono ; ° O rn o O -0 a, > v N O ~ E C C ' ) - o 41 > O Lm C = In ,0 i 0 -O O , 0) t 0n O O E 4- a) 7 y Q O O U s = Q = to (O i 00 • i1 +1 3 > O L' j f0 O O Vj 'A E c o t=o ai *1+ C Ln a co o x C a) °n (n . L l n O ~ L Q E O ° N Q d w o 41 p to E > = O L a) = E v In o L L E w In = - M g- Q c E a) to U x w o -C W E = v E te _0 0 3 N O N M In a) o = U O + > Q E _0 a ) _v L a) = o In I tin E h ~p cu u O ai o U M LA 45 o a) 'A W a) 4-- 4 = ° V) E co E 0n U 00 a) ti = a; O Y r, n) = _ In E E = co ro X a u 2 C) N E D =3 o .N . O Q- 4 dA U U E C7 4' L CL U w N d,p a D ~p p•, W Q. W O • • • • • • • • • • M d L u E ' 'O au t O M c n c ao d O = i L L :3 to a) C. a O 02 y > C O tn .o Q 2 C O O i cv U 0 N N d V V Q $ O C ~ N d " L 'C d CL ~a O p U u) V L = ~ i ~ N K V W L N 10- N~ C = O V ~ O Q n. E~ . ca c ~ o= O 00 E O d L° N m t 2 L d w~ W y U O O t LC L C U bB O vi tts a) C C Q. -0 E m Q v m o _ O 'r to L c ts O L O _ 0 u O L 'O t w L O 0 L to E OL Q ct5 Ln a C N " Ln N i O L O O CL V7• m 4- L Q V} L Q LL O d E c: 3 Y O c O = M 0 L. N N Q' C V1 ° L Q O O ~ +1 p c C Q) _ y . O C O O 0 L 0 'c 4- c o V j 41 C C w 0O ' E • 41 ~ aJ 41 4j C f6 A L- O C L- aJ in E C O\ O C' . 2 'U 40 N 4 v U vi 'a cts ra Q 2 v L V) LA E r-i O f0 N C O O l6 C 41 L C O a) Y C N O M m a- of ca ) 0 C h p> O 41 C VL N Q O c-I N L -E - 0 'L, O C 41 .Q Q) C O L 4J C Q N O a) E v E Ln O (v 0 0 0 L- w E -0 cu a) C E QJ a x L o a) m a' E fD to m 0 U a) u o m o (V m +1 > N X ° Q v L tw C 0 U C M f0 N m C a) 0 -O 0. s.. W C 7 Vt " O y E U O a) - m i 0 a) on Q U A 7 E 2 a m ' m~ N _O U L C c6 CL 0 O v) a C O a o E 0 a) Q cu Y co to V E 0 > cLts V) cc r- m -c: cu O p w v N + a) 'L a) co ca a + l6 C a ~ 0 u, wL N C H 4-- a) O E "a Ln C Ln m E E E O 0_ v L L o a) C , V m LM 7 = -0 I~ N ~ 'a O i l]A ~ U 4+ , co 'V p L a, L VI • V an V1 4! O W cu L p L o (]A -C cC L L O V1 = C c'I m 0 L p C m co W . L l9 L f0 m L O L C L m Co C W a) L 0 N O a) L -0 C V1 c o = n r-4 a m m E a Q LL a °v O S F- O m ~ . . C E p N m 41 m f0 N O ' 4 0 Ln Ln L 0 i••+ p vi ca p N a, _ O CL E v -0 o o row ate) t X 0 C CU 2 C is N 0 vi v- m . V U O L. a) O Ln a; c O 0 V) 0 ' j 4~ C 3 % ~ Q n L t m c a . E Q) L ao 4 Q) M CU V) O of O - 0 C p LL O Q a) a u ` a) NO c ca m W 0 O U C p f•a O Q O on GA X 0 M R o E O p p s C "O cats N p N Q L N Q) C f6 V) • M C a) Q) dQ. O C 1 'p p L ~ N C lC Vf p_ i1 ,0 V- +L•+ C C E a) f9 GA L C f0 = i 0 C Q. a) w'- 0 E Q a C p p a C ? v C its Lo a v v 00 Q) M X cu m 4- i O M cu c ' yL Z L O Q) Q) C V1 O O C -4-i "O O a) o Q m C -0 CL U -0 N N N V} ,E f6 p . L m VI lD 4 a) Y V) L C S ` a) Q) m _ L . v0- ~a 0 N O N O 0 Q- E m O L ca O 41 (n :5 Q) tn ZT CL C-4 M W -0 Q) L N W -0 0 ti p m O V O W E Z 4- E C M r4 L C L t o co L c° C C p C ' U L Vl N V) 0 O in vt vt a) C C C C O c E p (v N 41 p C O = L C 4- E t'..I T f15 -0 u x > 'p D a) -0 N x V x m E V1 N cts Q- M m O O O " 00 w ca R v1 a) 4+ h t V) ±J ~ a) a) Ln p m V1- C - L Q) L CE U • fn OL n c-I o -I a v a) m • "O E C C O V, L • a) p W 2 N Q ' N a) N C N E x x W Q) Q .E Q O -C Q x a) O • • • • • • • m i w = N E E _ N m Y E b4 V) O = -a 3 M u CL °J = oc m m ii 0 ..C Q C O O t ttf O 2 O cc N ix OC) a. IMo C N (0 O ^L C Ec L ccnn a) 40-'a C p O v cc 0 V N U = O 00- I- a~ O m E zo O C O t O ca =m i LL O vi 41 - C C Y C O to v, a) v m m aJ - a c 41 c O O a) N 4= a O in E Ln O M N d in M L t O p a1 co co "O a) > a) v O vi r 1 O ca Ln N v •u W v L " M Q > C C N On = c v, a 41 N a O a~+ O a a C a a) a) ' i O a) -p a C E ) O L M O M ~ ) C L to L co C O m a C Q a) . V, O O M a 0 N N O v p E -p O a co > > v C4- > L Q- r-l , Vf V, t U cu r-I a) o p a + O a1 O p -0 L L- m m 3 > U a) ~ o c C p c 1 L m a) i i N 'X C a to c a) U ) i, Q, O 0 a) O > t t O C 4-O In O N - CL O E ° 41 0 O a) - - i, L M O to r-' a co p 0 ,n C v Q) a O LL . > n a) m O m > ~ CL Q > -0 M O 0 o 5 4- T C L 07 C c =3 O a - CL > a a o cu } v a v U + V) 4.1 ° 4- ~ C'n ° v _ 0 Q CN a) 4 ~ - a V) a ~ a a~ o c c _ v a m vi J ca N O 1n C OA t a1 a) Q a) a- a L L- U O L a p 41 Lr) m o Vv 0 C = f° > N n ) n 3 ' an N j O O a1 p M a E a s -0 C c In v> m a a i ~ s U E m t L ~ _ c O v~ V, a o f -0 O a) C u E _ s 0 v m a) •3 m N Z ~ L C Y C O Q f6 Gn u 7 H ~ O r ca c a a O o -r - M O O of C 4- -0 L 0 p es to p O m O p c m a ns L) LL a) m (U C r- 00 E on M O V) a E U 4.1 H v Q Q M C L (a v o o a G u O V O C w o Q~ = p ~ > O ei CD Q O a 0 N Q M . Q n W V , 2 . N Li-- - m cu °1 On C O co O O L a) V) ) m C m n O M V U cu C O L v m c c o Y) NO -Fu c o 3 `n I-- L o " a i E ;n a) C -0 O +1 ~ ~ O N 7 In v E D to 7 a) a_~' O N f6 a) c v 'v, O O a c 4- c 0 Qj E N o 0 > N E ~ O i E . w m C a) a a) .Q c - a) V) O N w E L 4 E p L a E a) 'm > " a) U a) > O E O 0 v O fa O O > a) 0 O w m - c a C C 0 C _ 'U a) V 'O C o to N V) E o L C w L- CL .C qa O O oa O co cn c O L O L - s C 0 v o a) co a) j a a) " C - 41 E to ' E 4- w m p w a ° Ln ~ d o ° u o 3 V) ^ N L f0 (B E -C "O U N r+ cv c o a O 4- to • in U a) -0 \ -C O 'O n3 a o a) aj (U 4- 75 -a F+ - o Q) O c 0 Vf m (U 0 c O O CL 7 ' a) =3 a) = y_ a V) Z L- M m ' 0 Y d4 O CL L O > co -O U N m cu f6 a) a s t C if + 0 cu O U ` ca 0 a+ O a F N O O N N N M C~ co p C C C -0 Q C QJ cu L ~ ° O 4 C to a) > (U O p " O = X ca 7 L O O L 7 4+ = a) U p a u O a O a) n O O m 3 m u to a O N O a U a U a) *s- aa)) Q) U -a v Cl) c m 3 a U ~ ~ a L) p on Q C ~ t a) 41 C a) c y C a) co C a p O U 0 yU.. ca m O 4n C O i C L f0 i L 4- O O o Y O C - LL O 0 4- m .c - O co d C _ C L i GO aj N C C N N E 0 :t-- - ~n O d m V) 7 N -0 > C N a C c U Q N a) O C V a ' C cli O i O a :3 O C C _ N > =3 U a) c 0 O o a c a) V, > a) F to 06 t4 c a) u 3 > O O O E C . L m 41 C a -p CU C 4"' ) 0 N C C N U L a a) C N C j to a) a) v, C a i m U 1V -0 O d v E U U a `n N H a) " " "a c c a) > 0 j a) ca U X a) N O H a W a a) A 4 ~ Ln -0 i a) > a) OA N co m O C on v) C O O m (A C m =3 2 A) CL 0 CL) p W u n ~y Co > ' ca N C= o N 3 ' - " C "O ' w C a O L -a OO v L L m 41 ~ o O L ° 0 of t O M O ~ t"1 L a) "a m M - m t"'I 0 • U O CL C O Q) O C LA aj on > ce 0 C C S C O a) u Q p > p > L N p . i L p L • U Q O f O C U o U > C CL C:) O O m a) a) O c o a) C kn c n > N co = U `n O V) CL) L C cn U > ca a) a) a) L L C ~ ' N m N - E C m L 'L H N N i VI N V) a , i, > E U N O Q) -6 Q 0 p m 0 cu U O In L C O a. m L c C ca -0 G m L N O C w v 3 Q O U 4- o a) a a) a) a) 4! L Q a) L • • • • • • • • m L Q s G m L nc s OL C H n, g c o_ N U 7 ' > a o ° a Q, N 'i O O Q m a) c O v L O t l~ d O ~o Q N O° 0.4 O O '.J fII rn L ~ Q E~ ns L ~ ao c ' O m aa) v 0 (o a= E06 U_ O 00- L a~ 0 ~ 2 •S O E au) L. 40-0 N Y.. C O m =m L d LL O } y E C N a- E of L L ai of a) 0 U a Q S co O t E to N 1-1 V o 0 C O Q cu dA 0 C c aj p M O C v- L C O cU = > - 4- N m m U 0 - CIJ M cu -0 CL o tp o M N CL Q w a ri bn L C W 4- a- CU 0 m .L p (v N 0 (u f0 N 0' 0 N O of O _ o C t CL m aj N O p to ~n 4 1 - N -Fu O C t O CL N C of O C E to m -0 N CU - L IQ 0 = M - C: -0 LL a L OA O O U +L-+ OC p LL E ~ +L+ a O OL 'a x 4- t -0 @ - v C Q OA 4- C W e-I CL =3 U 4~ L >-0 i ~ L O M C C a 4- a1 NO Z ro N m LA - to I- =3 cr co to .0 'a U 0 C LA (D o Q' ° > m - L 1 U ~ C C ` ° E 4- fl- M c m cn ° u tin ,O Q O L Q U a1 a) o c 'O vi ~ ? 4 J - -0 ao rn _0 m m ) C O L . \ E_ m fl. ri 0' - 0 m a J bA U = Q- D N -0 OM a) ND u OU v3. (n M NO W O H - a) 3 LL (v " O a C N C N "a 4 O O O o D o Q v W C Q a. m 0. L a) 4- o O _0 E = v) Ln C 3: to 40 O pp QJ a E aJ c c } > cv • CL O a 0 C Q 7 O 0 a1 O i O N 07 w + cr L + c C C "a f0 L + m L H E L 0 (U a1 In O= 0 ° C =3 O ca O v A in O j m O a c Qj L C " - aj rn O cu x N 2 L; LA v E 0 Q Ln ai t ~ c o y 4 a a v w :5 m o 3 0 O 3 0 ~ a v i > - L. V) a, :t C v a E c j -C tw 4- 0 U L -0 tw O H t n C aJ Q1 N 3 C O C v c 0 a Q_ co Q vi m E= a) C cn N : v- 0 . E u a 16 = g o a) 6 ) o v 4- a o a) - n -C ,n ± a, 4~ -o c 75 w o ro ' v) m -0 ,n - c E ° 4- 3 d -C o°JC = 3 c o 4:; t N c Q m c C u a) C a' to 0 m c E vUi C "a a) u 0 a' 3 U u C O ar c 4- Q 0 u M C O W = p a1 C C ca O w- o a) tLo ` aJ 7 a) cu U z i L t L a1 L o to H = w L N C } L 1 C J ~ > O i 0 ` Y O v E 23 O - • N N p a) 4- 0 0 0 3 m C O C oA J L o~ Q U m L w = C C y C o N M CICI L O Q QJ ~ L L 0 H c O E o _ v v a w N Ln 4 pQ ,o E E a z ` ° ~ a c ~ c v 0 m aj 3 w ao L `L° v to " to v a i o `L° v = o 0 co 6 > L H O O Q QJ N M Z L N L fG L ' 0 O Q. 6 'O O = Q O O aj f0 U v - m aj a > a, ca Co a a, n " 0 3 cn j i O a) 4+ ai m . O o v cn co a) C U O "p a) O J = N v i 'm m in C Y o r U bo a) N L fa aj O +1 L m _ C of Q. = O aJ w >4- L M O + u O o a) \ m C a) Ln i L N 0 C ° O in v1 0 U E C > z to f6 ,0 i 3 i a a `L° o v 0 0 0 m 0 u M U N C (U to C C 0 + C a°1o ro m + O Q -a > f0 C 0 C = a O r 0 L O O L 7 N i>Q ) U 7 CU L N o v v a z a > CL N •0 m> N L u a u (A E to v aJ O E a) d o 4. +J O v 0aj f0 - > C- O O O O O _ U +J L O C U 'L O L.L. a+ aU cn o a v N w- a a) 0 p • • • • • • . • m d L L Q E U 42 v m- L to 4~ Q' IA t O L L a 0 w n: u • 0 y 0 ' a a m a 3 a~ c m M a 0 L Q t m c 0 ao v L O